Client Health History Form Massage Therapy Details

The Massage Health History Form (MHHF) is designed to provide a complete overview of your health history and current health status. Completing the MHHF is mandatory for all clients receiving massage therapy services. The information you provide will help your therapist better assess your needs and create a treatment plan that meets your specific needs. Please take the time to complete the form fully and accurately.

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QuestionAnswer
Form NameMassage Health History Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesbody treatment consent form, massage history form, remedial massage health history form, client history form template

Form Preview Example

Massage Client Health History Form

Client Information and Release Form

Name ____________________________________________________ Birth Date ____________________

Address ________________________________________________________________________________

City __________________________________________ State ________ Zip ________________________

Phone Number(s) ___________________ Home __________________ Work __________________ Cell

E-mail Address__________________________________________________________________________

Referred By ________________________Is this your first massage?________________________________

General Medical History

Check the box if you have or have had recent problems with any of the following:

Arthritis

High Blood Pressure

Sinus / Allergies

Bursitis

Low Blood Pressure

Hematomas

Back Pain

Poor Circulation

Phlebitis

Neck Pain

Anemia

Vericose Veins

Arms / Hands (Pain)

Stroke

Cancer

Hips / Legs / Feet (Pain)

Chest Pain

Skin Conditions

Headaches

Seizures / Convulsions

Pregnant? ____# of months

Swollen Joints

Heart Conditions

Menstrual Pain

Fibromyalgia

Constipation

Warts

 

 

Athlete’s Feet

Please circle any areas of pain, injury, tension, or restriction of movement.

Have you recently suffered an acute injury? _____________________________________________

Have you had any recent surgery? ____________________________________________________

Do you have any other medical conditions that I should be aware of? _________________________

Where do you carry your stress and tension? ____________________________________________

Do you wear contacts? _____________________________________________________________

Do you have any problem areas / injuries? ______________________________________________

Do you take any prescription medications? ______________________________________________

Do you have any allergies? Yes or No, and if yes what are you allergic to? _____________________

Describe exercise activities that you do. Include Frequency. ________________________________

Are you very sensitive to touch / pressure in any areas? ____________________________________

What type of pressure do you like? ____________________________________________________

What is your goal in the session today? _________________________________________________

Please list any additional comments regarding your health and well being if needed. _____________

________________________________________________________________________________

Your answers to these questions will be discussed with you prior to your session. Thank You.

Please take a moment to carefully read the following information and sign where indicated.

I understand that the massage I receive is provided for the basic purpose of relaxation, stress reduction, and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and / or strokes may be adjusted to my level of comfort.

I further understand that massage should not be considered as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment that I am aware of.

I understand that massage practitioners are not qualified to perform spinal or skeletal adjustments, diagnosis, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session(s) given should be considered as such. Further, no comments or gestures that are sexual in nature will be tolerated by the massage therapist. In the event that I violate this policy, my session will be immediately terminated.

Because massage is contraindicated under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile, and understand that there shall not be liability on the practitioner’s part should I forget to do so.

Signature______________________________________________________Date _____________________

Consent for minors is required prior to treatment.

Signature of Guardian____________________________________________ Date _____________________

Printed name of Guardian __________________________________________________________________

Phone number the Guardian can be reached in case of emergency __________________________________