Health History Form
This form must be completed and submitted before your first appointment.
First Name *
Your answer
Last Name *
Your answer
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Street Address *
Your answer
Apt/Suite
Your answer
City *
Your answer
State *
Required
Zip Code *
Your answer
Phone Number *
Your answer
Untitled Question
Email *
Your answer
Would you like to receive our free e-newsletter?
Occupation *
Your answer
Who referred you? How did you hear about Rx Massage Therapy? *
Your answer
Describe major complaint (be specific) *
Why are you seeking massage therapy? When and how did your condition develop? What makes your condition worse? If auto accident, give date and description.
Your answer
Your overall pain *
No Pain
Maximum Pain
Are you currently getting treatment from other practitioners?
List diagnosis (if known):
If available, please email or bring printed reports: MRI, X-rays, Medical
Your answer
If so, what is your current treatment plan?
Results from previous massage therapy and/or physical therapy treatments
Your answer
Name of treating healthcare practitioner
Your answer
Street Address
Your answer
City
Your answer
State
Zip Code
Your answer
Healthcare Provider's Phone Number
Your answer
Primary Insurance Comapny
(Rx Massage Therapy does not currently accept or bill health insurance.)
Your answer
Emergency Contact *
First and last name.
Your answer
Phone Number *
Your answer
Relationship
Your answer
General Health Information
Activities/Lifestyle (forms of and frequency of exercise) *
Explain your daily/weekly physical activities? What is your workout frequency and intensity, etc?
Your answer
List ALL medications, supplements and their purpose *
If you are currently on prescription blood thinners, you will not be able to recieve massage therapy.
Your answer
Do you have any skin disorders or allergies (i.e. varicose veins, rash or latex allergy)? *
No or Yes (If Yes, please explain)
Your answer
Are you pregnant? N Y – estimated due date
No or Yes (If Yes, what is the estimated due date?)
Your answer
Do you have any other medical condition or physical limitation that I need to know before you receive this bodywork?
No or Yes (If Yes, please explain)
Your answer
Check all that apply (present or past) *
Required
Significant Current and Previous Injuries *
Include date(s) or type "None"
Your answer
List ALL Surgeries (month and year) *
All surgeries have significance. Please list all. Type "None" if applicable.
Your answer
Do you believe that massage therapy will help you? *
How frequently do you get massage therapy?
Weekly
Bi-Monthly
Other
A couple times a year
My last birthday or vacation
I've never had massage therapy before
Monthly
I usually get a massage...
I WANT to get massage...
I have listed ALL my known medical conditions, physical limitations, and medications. I will inform my therapist of any changes in my physical health or medications. I understand that a licensed massage therapist does not diagnose illness, disease, or any other medical, physical or psychological disorder, nor performs any spinal manipulations. I am responsible for consulting a qualified physician for any problems that I have. I agree to pay for all services at the time they are rendered, unless prior arrangements have been made. CANCELLATIONS and MISSED APPOINTMENTS: Unless you are ill or have an emergency, we require 24 hr. notice for any schedule changes, or you may be responsible for the full session fee. We cannot do bodywork sessions if you are sick. If there is a question, please call. I understand the information contained herein is privileged and confidential. I authorize the release of any information pertaining to my health to my attorney, insurance company, or referring physician / therapist. *
Required
I agree to the Policies and Procedures. https://www.rxmassagetherapy.com/policies.html *
Required
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