Health History Form
This form must be completed and submitted before your first appointment.
First Name *
Last Name *
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Street Address *
Apt/Suite
City *
State *
Required
Zip Code *
Phone Number *
Untitled Question
Clear selection
Email *
Would you like to receive our free e-newsletter?
Occupation *
Who referred you? How did you hear about Rx Massage Therapy? *
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 overall pain *
No Pain
Maximum Pain
Are you currently getting treatment from other practitioners?
Clear selection
List diagnosis (if known):
If available, please email or bring printed reports: MRI, X-rays, Medical
If so, what is your current treatment plan?
Results from previous massage therapy and/or physical therapy treatments
Name of treating healthcare practitioner
Street Address
City
State
Zip Code
Healthcare Provider's Phone Number
Primary Insurance Comapny
(Rx Massage Therapy does not currently accept or bill health insurance.)
Emergency Contact *
First and last name.
Phone Number *
Relationship
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?
List ALL medications, supplements and their purpose *
If you are currently on prescription blood thinners, you will not be able to recieve massage therapy.
Do you have any skin disorders or allergies (i.e. varicose veins, rash or latex allergy)? *
No or Yes (If Yes, please explain)
Are you pregnant? N Y – estimated due date
No or Yes (If Yes, what is the estimated due date?)
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)
Check all that apply (present or past) *
Required
Significant Current and Previous Injuries *
Include date(s) or type "None"
List ALL Surgeries (month and year) *
All surgeries have significance. Please list all. Type "None" if applicable.
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...
Clear selection
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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