Vous êtes sur la page 1sur 2

CLIENT HEALTH HISTORY

Name: ________________________________________ Date of Visit: ______________________________________


Address: ________________________________________________________________________________________
Primary Phone Number: ________________ Secondary Phone Number: ___________________________________
Birth Date: ___________ E-Mail Address: _____________________________________________________________
Occupation: __________________________________ Length of Time: ____________________________________
Name of Nearest Relative: _________________________ Phone: _________________________________________
Who May We Thank for Referring You? ______________________________________________________________
Purpose of this appointment: _______________________________________________________________________
Date Symptoms Appeared: _________________________________________________________________________
Have you ever had the same or a similar condition? Yes
No If yes, when and describe: ___________________
________________________________________________________________________________________________
List any Surgeries the past FIVE years:
________________________________________________________________________________________________
List any Accidents or Injuries in the past YEAR:
________________________________________________________________________________________________
Have you been treated for any health condition by a physician in the last year? Yes
No
If yes, describe: ___________________________________________________________________________________
What medications or drugs are you taking and how often?
________________________________________________________________________________________________
________________________________________________________________________________________________
Do you have allergies of any kind? Yes
No
If yes, describe: ___________________________________________________________________________________
Women: Are you pregnant or trying to become pregnant? _______________________________________________
If so, how far along are you: ____________ Have you had any complications? Yes
No
If so, please describe: _____________________________________________________________________________
Do you have any other children? Please list names and ages:
________________________________________________________________________________________________
What sorts of scents do you like? ___________________________________________________________________
Please list any hobbies you have and how often you participate in them:
________________________________________________________________________________________________
________________________________________________________________________________________________
Have you ever had a professional massage? Yes
No
How many? _________________ How often? __________________________________________________________
How do you want to feel after your massage: _________________________________________________________

Have you had or do you now have any of the following symptoms/conditions? Please indicate the conditions you have
now with a CHECK MARK if you have had these conditions previously.
Allergies/Asthma

Headaches: Frequency _________

Pain (please specify where)

Sleeping Problems

Broken Bones/Fractures

Tension

Depression

Weight Gain/Loss

Seizures/Epilepsy

Skin Conditions

Eating Disorders

Ulcers

Fainting

Loss of Balance

Nervousness

Unusual Bowel Patterns

Stroke

Arthritis

Diabetes

Chest Pain/Tightness

Muscle Spasms

Breathing Problems

Dizziness

Numbness in Fingers

Fatigue

Sinus Problems

Pacemaker

Light Bothers Eyes

Ears Ringing or Buzzing

High/Low Blood Pressure

Weakness in Extremities

Joint Pain/Swelling

Loss of Memory

Circulation Problems

Osteoarthritis

Heart Disease

Cancer

Rheumatoid Arthritis

HIV Positive

Other __________________________

SOCIAL HISTORY
Please indicate beside each activity whether you engage in it:
OFTEN= O SOMETIMES= S NEVER= N
__________ Exercise
_________ Family Pressures
__________ High Stress Activity
_________ Financial Pressures
__________ Alcohol Use
_________ Other Mental Stresses
__________ Drug Use
Other (specify)________________
__________ Tobacco Use
____________________________
__________ Caffeine
____________________________
Use the area below to tell us where you'd like to focus, to avoid, and to describe your symptoms and pain:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

Mark your pain and problem areas and beside them rate it on a scale of 0-10. 0 means no pain, 10 is you need to be
taken to the emergency room immediately.
I CERTIFY THAT THE INFORMATION PROVIDED IS ACCURATE TO THE BEST OF MY KNOWLEDGE AND WILL
NOTIFY THIS PRACTICE OF ANY CHANGES IN MY HEALTH AND/OR MEDICATIONS AS NEEDED. I UNDERSTAND
THAT THIS INFORMATION IS TO HELP TREAT ME TO THE BEST OF THE PRACTITIONERS ABILITY.
Signature of Patient or Legal Guardian: ______________________________________________________________
Date: _____________________________ Therapist's Initials ____________________________________________