Trends…
Alternative Healing
Health History Intake Form
Massage, Hot Stone Massage, & Reflexology
Client Name: _________________________________ Date: ________________
Address: _____________________________________________________________
City: _________________________ State: __________ Zip: _______________
Contact Number: ________________________ Cell Number: ________________
Date of Birth: ________________ Occupation: ___________________________
Emergency Contact: ________________________ Relation: __________________
Emergency Contact #: ____________________________Cell #: _______________
Current Health Information
List Health/Concerns Circle all that applies
Primary Concern ________________________________________________________
Area of discomfort is: Mild – Moderate – Disabling
Secondary Concern _____________________________________________________
Area of discomfort is: Mild – Moderate – Disabling
Have you every received Manual Therapy before? Y or N –
How frequent: ______________________
Please list all conditions currently monitored by a Health Care Provider:
______________________________________________________________
List Medications you took today/last 3 months (include pain relievers and herbal remedies)
_____________________________________________________________________
______________________________________________________________________________
What are your goals for receiving Manual Therapy: _______________________________
______________________________________________________________________________
List and explain. Include dates and treatment received:
Surgeries: __________________________________________________________
_____________________________________________________________________
Accidents: ___________________________________________________________
_____________________________________________________________________
Major Illnesses: ______________________________________________________
_____________________________________________________________________
Circle all Current and Past Conditions: Mark C for current or P for past.
General Allergies
Sleep Disturbance Seasonal
Infectious Scents, Lotions, Oils
Sinus Aloe/Bees Wax
Headaches Other:
Pain Nervous System
Fatigue Dizziness, Ringing In Ears
Fever Numbness Tingling
Other: Epilepsy
Skin Conditions Loss of Memory/Concussion
Rashes Sciatica/Shooting Pain
Athlete’s Foot/Warts/Fungal Depression
Other: Chronic Pain
Other:
Muscles & Joints Blood Clots
Osteoarthritis High/Low Blood Pressure
Osteoporosis Poor Circulation
Rheumatoid Arthritis Chest Pain/Shortness of Breath
Broken Bones Digestive/Elimination System
Lupus Colitis
Scoliosis Gas/Bloating
Spinal Problems Abdominal Pain
TMJ/Jaw Pain IBS
Tendonitis/Bursitis Bladder/Kidney Dysfunction
Weak or Sore Muscles Other:
Low Back, Leg, Hip Pain Endocrine System
Gout Diabetes
Spasms, Cramps Thyroid Dysfunction
Stiff or Painful Joints Other:
Neck, Shoulder, Arm Pain Reproductive System
Other: Pregnancy
Respiratory, Cardiovascular Painful Menses
Stroke Endometriosis
Varicose Veins Fibrotic Cysts
Irregular Heart Beat Other:
Swollen Ankles Cancer/Tumors
Asthma Malignant:
Heart Disease Benign:
Other:
Contract for Care I promise to participate fully as a member of my health care team. I will make sound choices
regarding my treatment plan based on the information provided by my manual therapist and other members of my
health care team, and my experience of those suggestions. I agree to participate in the self care program we select, I
promise to inform my practitioner any time I feel my wellbeing is compromised. I expect my manual therapist to
provide safe and effective treatment.
Consent for Care It is my choice to receive manual therapy and I give my consent to receive treatment. I have
reported all health conditions that I am aware of and will inform my practitioner of any changes in my health.
Signature: _________________________________________ Date: __________________________________