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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?
Sex (As noted on legal records).
What is your general health status?
Are you currently experiencing any of the following?
Have you had a professional treatment before?
What is your current discomfort / pain level?
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.
Have you received treatment from other Healthcare Practitioners? (Check if applicable.)
How did you hear about us?

Thanks for making the time!

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