activebodylasalle_Massage_Health

Massage Therapy Health History Form
Name
Date of Birth

MonthDayYear
Date
Have you received massage therapy before?

YesNo
Did a health care practitioner refer you for massage therapy?

YesNo
If yes, please email prescription to: forms@activebodytherapy.com

Please indicate conditions you are experiencing or have experienced:

Cardiovascular

	Self	Family
High blood pressure
Low blood pressure
Chronic congestive heart failure
Heart attack
Phlebitis/ Varicose
Stroke/ CVA
Pacemaker/ Similar device
Heart disease

Respiratory

	Self	Family
Chronic cough
Shortness of breath
Bronchitis
Asthma
Emphysema

Infections

HepatitisSkin conditionsTBHIVHerpes
Infections

HepatitisSkin conditionsTBHIVHerpes
Head/Neck

History of headachesHistory of migrainesVision problemsVision lossEar problemsHearing loss
Other Conditions
Loss of sensation, where?
Diabetes , onset: allergies/hypersensitivity to what?
Cancer, where?
Skin conditions, what?
Arthritis
Is there a family history of arthritis?

YesNo
Women
Pregnant, due:

MonthDayYear
Date
Gynaecological conditions, what?
Overall, how is your general health?
Primary Care Physician:
Physician Address:
Current Medications:
conditions it treats:
Are you currently receiving treatment from another health care professional?

YesNo
If yes, for what?
Do you have any other medical conditions? (e.g.digestive conditions, haemophilia, osteoporosis, mental illness)

YesNo
If yes, what?
Do you have any internal pins, wires, artificial joints or special equipment ?

YesNo
If yes, what and where?
What is the reason you are seeking massage therapy? Please include the location of any tissue or joint discomfort
Surgery date

MonthDayYear
Date
nature
Injury date

MonthDayYear
Date
nature
Lymphatic clients please fill out the following: Please list your area(s) of concern with symptoms
Are you post cancer?

YesNo
If yes, how long post cancer? ______years/months.
NOTE: Less than 5 years post cancer requires a Doctor's prescription BEFORE treatment can begin.
Do you have Lymphedema or Lipedema?

YesNo
If yes, what areas are affected?
Do you wear compression garments?

YesNo
If yes, please bring all your garments on your first appointment.
What are your goals for treatment?

Decrease in swelling and sizeDecrease in painIncrease in range of motionOverall general healthDecrease pregnancy swellingDecrease in heavinessPre and post surgeryPost cosmetic surgeryOther
Do you require an ADP form completed?

YesNo
Massage Therapy Cancellation Policy

**All fees are charged at the discretion of your therapist. ***

If you fail to attend your scheduled massage appointment, the following fees will be charged. Please note that you cannot use your benefits/insurance to pay for missed appointment charges. If you need to cancel your massage appointment please give 24 hour notice to avoid paying a cancellation fee. To help you avoid missing appointments we give reminder calls the night before your massage.

First missed appointment - $35

Second missed - appointment100% of appointment price charged

I have read and understood these policies
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Massage Therapy Health History Form

Massage Therapy Cancellation Policy