Health History Form

Confidential Health History Form

All information is held in the strictest confidence.

At no given point is information disclosed or shared without client’s written consent.

Name*

First NameLast Name

Today's Date

Date

Email*

example@example.com

How did you hear about West Trail Wellness and Massage?

Whom should we thank for referring you?

Other:

Have you previously received a professional massage?

YesNo

Are you comfortable lying on your front, back, and side?

YesNo

If no, please explain:

Do you have an allergy/sensitivity to any ingredient that may be in massage oils, lotions, cremes, or ointments?

YesNo

If yes, please explain:

MEDICAL HISTORY

Are you currently under medical supervision?

YesNo

If yes, please explain:

Please check any condition listed below that applies to you:

If you checked any of the above conditions, please provide more information:

Have you had any implants within the last 9 months? (Cheek, chin, breast, pectoral, calf, etc)

YesNo

Please indicate location of your implant:

Medications

Coumadin, Lovenox, Heparin, PlavixHigh dosage of aspirinPain killersMuscle relaxers

Females: are you pregnant or trying to become pregnant?

YesNo

Please circle areas of pain or discomfort:

Is there anything else about your health history that you think would be useful for your massage therapist to know in order to plan a safe and effective massage session for you?

Massage Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.

• Please silence your cell phone for optimal relaxation.

• You will have a consultation with your massage therapist to discuss the objectives of your session.

• After your therapist has left the room, you may disrobe to your comfort level. You will be professionally draped with a sheet/blanket at all times.

• I understand that my massage therapist or I may end the session at any time for any reason.

• Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law.

Client Agreement:

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed 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 therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed 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 therapist updated as to any changes in my medical profile and I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless West Trail Wellness and Massage, LLC and my massage therapist from any liability whatsoever arising from failure on my part.

By my electronic signature below, I agree to the massage policy and client agreement above.

Signature