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					                                                             Elevate Therapeutic Services
                                                                 106 Main St. N, Unit #11
                                                                   Uxbridge, ON L9P 1R1
                                                                          (416) 910‐6172

                                               jasmine@elevatetherapeuticservices.com
                                      HEALTH HISTORY FORM
Personal Information

Name:                                                        Date:
Address:                                                     Phone (home):
City and Postal Code:                                        Phone (work):
Date of Birth:                                               Occupation:
Height:              Weight:                    Sports and Hobbies:
Medical Doctor Information:
Where did you hear about the clinic?
What is the reason for your massage therapy visit?
Do you have insurance coverage for Massage Therapy?
E-mail: ______________________________________________________

Healthy History
(Please check off the conditions that you are currently experiencing or have experienced often in the past)

HEAD/NECK                                   HIVS, AIDS                             diabetes
  headaches                                 other:                                 gallbladder
  (type:                        _)                                                 liver / kidney
  vision problems                        WOMEN                                     allergies
  hearing loss                            menstrual problems                       cancer (type:            )
  earaches                                gynecological surgery                    epilepsy
  other:                                  pregnant                                 multiple scelorisis
                                          children                                 Parkinson’s disease
RESPIRATORY                               menopausal problems                      osteoporisis
  chronic cough                           other:                                   fibromyalgia
  pneumonia                                                                        chronic fatigue syndrome
  shortness of breath                    CARDOVASCULAR                             artifical joints/limbs
  smoking                                  high blood pressure                     use wheelchair/walker
  breathing disorders                      low blood pressure                      thyroid
  (type:                        _)         poor circulation                        other:
  other:                                   heart disease/heart attack
                                           pacemaker                           MUSCOSKELETAL
SKIN                                       chronic heart failure                 joint sprain:
  skin conditions                          stroke                                muscle sprain:
  (type:                         )         varicose veins                        fracture:
  bruise easily                            other:                                dislocation:
  planter warts                                                                  whiplash:
  other:                                 OTHER CONDITIONS                        low back pain:
                                           difficult digestion                   arthritis:
INFECTIONS                                 constipation                          carpal tunnel sydrome
  hepatitis                                Crohn’s disease or colitis            other:
  tuberculosis                             ulcers
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                                                        Elevate Therapeutic Services
                                                            106 Main St. N, Unit #11
                                                              Uxbridge, ON L9P 1R1
                                                                     (416) 910‐6172

                                       jasmine@elevatetherapeuticservices.com


Injury and Surgery
(Please list off any injuries or surgeries that you have had in the past which may affect any massage therapy
treatment)


Type:                                 Type:                                   Type:
Date:                                 Date:                                   Date:
Current symptoms:                     Current symptoms:                       Current symptoms:




PAIN AND STIFFNESS                                         OTHER INFORMATION
(Please check off any areas of the body where you are      (Please list any other personal or health information
experiencing any pain or stiffness)                        which you feel is applicable to your massage therapy
                                                           needs or treatments)
         jaw neck
         shoulders
         upper back
         mid back
         lower back
         elbow (left or right)
         wrist (left or right)
         hip (left or right)
         thigh (left or right)
         knee (left or right)
         leg (left or right)
         ankle (left or right)
         other:




I understand that the information that I give on this Health History Form will be confidential and will be
used for no other purpose other than the registered massage therapist’s records. The Massage Therapy
Act, 1991 requires that every client’s health record be maintained for at least ten (10) years from the date
of their last visit. You may access copies of your client health record at any time by contacting Jasmine
Mathews R.M.T.

Signature:                                                Date:

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