Health History Form

An accurate Health History Form is required by law and is necessary to ensure that it is safe for you to receive a Massage Therapy Treatment. It is important to help design the most effective treatment plan. Answer all questions to the best of your ability. All client information will be kept confidential unless allowed or required by law, in which written authorization would be obtained prior to release of information.

Please note, the appointment time includes completion of any outstanding paperwork, consultation, assessment, change time and treatment.

If the client is under 16 years of Age a Parent / Legal Guardian Signature of Consent is required

What treatments might you want to receive?

Massage Therapy

Reiki

Intuitive Guidance | Coaching

Spiritual Healing Journey Support

First Name

Preferred Name

Last Name

Phone Number

Select an Address

Birth Date

Occupation

Emergency Contact Full Name

Emergency Contact Phone Number

Emergency Contact Relationship to You

Family Doctor

Family Doctor Phone Number and Email if Known

Sex (As noted on legal records).

Female

Male

What is your general health status?

Excellent

Good

Fair

Poor

Do you exercise regularly? If so, how many times per week and what types?

Average Hours Sitting Per Day

Average Hours Standing Per Day

Average Hours Slept Per Day

If so, when was your last treatment and what is your treatment frequency?

Primary Reason and Expectations for this Treatment

What type of discomfort are you experiencing and where?

When was the onset of discomfort / pain and what is its frequency?

What makes the discomfort / pain better?

What makes the discomfort / pain worse?

If clinically relevant, as discussed with my Massage Therapist / Practitioner / Facilitator, I consent to have these sensitive areas assessed and treated. This consent applies for my initial, and all future, assessment(s)/treatment(s) and I understand that I maintain the right to withdraw my consent at any time by verbalizing it to my Massage Therapist / Practitioner / Facilitator.

Anterior Chest Wall (Including Pectoralis Muscles)

Upper Inner Thigh(s) (Including Adductors/Hip Flexors)

Breast(s)

Abdominal Region

Gluteal Region (Buttocks/Hips)

Please list any medications you are currently taking and what they are used for.

Please list any use of controlled substances and their purpose.

Please list all surgeries / fractures / injuries / presence of pins / plates.

Musculoskeletal Conditions: Please list all, past and present.

Cardiovascular Conditions: Please list all, past, present and family history.

Respiratory Conditions: Please list all, past and present.

Neurological Conditions: Please list all, past and present.

Skin Conditions: Please list all, past and present.

Gastrointestinal Conditions: Please list all, past and present.

Other Conditions: Please list all, past and present.

Female Conditions: Please list all, past and present.

Infectious Disease: Please list all, past and present.

Please list all allergies / sensitivities and reactions.

Please provide any additional details in preparation for your treatment.

If this treatment is for a youth (under 16 years of age) please share the parent / guardian's first and last name and their relationship to the client.

I would love to subscribe to the newsletter / email updates!

Consent for Treatment | I, the undersigned, have read, understand, and completed, to the best of my knowledge, this Health History Form. I confirm that I read, write, and understand English well. I have alerted the Massage Therapist / Practitioner / Facilitator of all my conditions / medications up-to-date. I understand and agree that it is my responsibility to keep the Massage Therapist / Practitioner / Facilitator up-to-date on any changes in my health history. I release the Massage Therapist / Practitioner / Facilitator from any and all liability from problems arising in the treatment as a result of health history omission. I understand that I am receiving Massage Therapy, Reiki and other modalities as requested with informed voluntary consent at my own risk. In the event that I become injured, either directly or indirectly as a result, in whole or in part, of the aforesaid Massage Therapy, Reiki and other modalities, I hereby hold harmless and indemnify the Massage Therapist / Practitioner / Facilitator, their principals and agents from all claims and liability whatsoever. I understand that I may ask questions about the information being requested and my therapy at any time. I understand that all Massage Therapy, Reiki and other treatments will be discussed and planned with the Massage Therapist / Practitioner / Facilitator and will require my informed, voluntary consent and that I may withdraw my consent at any time by verbalizing this to my Massage Therapist / Practitioner / Facilitator and the treatment / session will be stopped. I understand that all client information is confidential and written authorization will be obtained prior to release of information. I understand the general benefits of the Massage Therapy, Reiki and Other Treatment(s) as well as the utilization of any other tools/products including, but not limited to, Myofascial Cupping, Kinesio Taping, essential oils, smudging, hot towels, crystals, possible contraindications and precautions, the assessment and treatment plan, the body areas to be massaged / treated, that draping will be used to expose only those areas that require treatment, and that it is my responsibility to communicate any discomfort during treatment (such as, but not limited to, adjustment of pressure / temperature / lighting / sound / positioning / techniques utilized); I consent to receive these treatments and any combination of them. I understand sexual advances, request for sexual favours, and other verbal or physical conduct of a sexual nature will constitute as sexual harassment and will not be tolerated. I understand, if it occurs, the treatment will be stopped immediately and I will be required to pay the entire cost of the treatment booked. I understand that Massage Therapy, Reiki and other modalities are not a substitute for medical treatment or medications and that it is recommended that I work with my Primary Caregiver for any condition(s) I may have. I understand that a Massage Therapist / Practitioner / Facilitator does not diagnose illness or disease and does not provide written prescriptions for medication(s). I understand that this Health History Form will be reviewed yearly for any necessary updates and a new Health History Form is required if it has been 1+ year since my last Massage Therapy, Reiki, Other Treatment at this location. I understand the duration and cost of the Massage Therapy, Reiki, Other Treatment, that the appointment time includes the consultation, assessment, change time and treatment. I understand there are alternate treatment options (i.e. chiropractic, physiotherapy, acupuncture, rest, etc.). By checking the box I confirm I have reviewed this policy, I understand it and I agree to abide by its terms.

Privacy and Sharing of Information | I authorize the health professionals / facilitators / business to collect my personal and medical information as documented above. In addition, I authorize the health professionals / facilitators / business to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission. By checking the box I confirm I have reviewed this policy, I understand it and I agree to abide by its terms.

Appointment Change Policy | Your time is valuable. We require 72 hours notice if you need to cancel or make changes to your appointment. Failure to do so, or failure to show up for your treatment, will result in a charge of 100% of the scheduled treatment cost. This helps ensure others in need may book their treatment and ensures your appointment time is not ever affected by a change in someone else’s appointment. If you are going to be late for an appointment please let us know. If you are unable to make it within the first 15 minutes of your scheduled treatment it will be considered as a failure to show up and charged as such. By checking the box I confirm I have reviewed this policy, I understand it and I agree to abide by its terms.

Your Signature

Thanks for making the time!