The information request below will assist us in treating you safely. Feel free to ask any questions about the information being requested. All information will be kept confidential unless allowed or required by law. Your written permission will be required to release any information.
Friend/RelativeHealth Care PractitionerGoogleYellow PagesOther
High Bld PressureLow Bld PressureChronic Congestive Heart FailureHeart AttackPhlebitis/Varicose VeinsStroke/CVAPacemaker or Similar DeviceHeart Disease
Chronic CoughShortness of BreathBronchitisCOPDAsthmaEmphysemaPneumonia
ShinglesPlantar WartsHepatitisSkin ConditionsTBHerpes
History of HeadachesHistory of MigrainesVision ProblemsVision LossEar ProblemsHearing LossWhiplashConcussion
SprainStrainsBroken Bone/sShoulder SeparationHerniated DiscJoint Replacement, where, when
Loss of SensationArthritis OA or RADiabetesAllergiesEpilepsyCancerOsteoporosis
How long have you had this condition?
mild 12345678910 severe
ConstantIntermittentCertain MovementDull PainAchySharp PainBurningTinglingSwelling
I have completed an accurate health history and agree to make known to the therapist should there be any changes to my health including medication changes. I understand I can ask any questions and that if at any time I feel uncomfortable I can ask the therapist to stop or alter the massage. Should I experience any unusual sensations during the massage I will let the therapist know.
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