Health History Form - Escapes Spa

First Name

Last Name

Date

Phone

Referred by

Address

Address Line 1

Address Line 2

City

Country

Select

State/Province

Select

Zip Code

Date of Birth

Primary Care Physician

Current Medications

Allergies

Please describe/explain any condition you marked above.

Have you received care from any of the following?

Check all that apply.

Physiotherapist
Chiropractor
Massage Therapist
Naturopath

If you've received care from any of the above professionals, please explain the reason for treatment and number/duration of treatment(s).

Have you had surgery in the past? If yes, please describe?

Have you had any fractures or sprains in the past? If yes, please describe?

Have you had a serious illness in the past 6 months? If yes, please describe.

If you have any current injuries, did they result from a motor accident or workplace accident? If yes, please describe.

Have you had any of the following procedures performed regarding your current condition?

Check all that apply.

Physical Examination
X-ray
Computed Tomography (CT scan)
Magnetic Resonance Imaging (MRI)
Discography
Ultrasound Imaging
Other

Are you currently pregnant or is there a possibility that you may be pregnant?

What relieves your pain/discomfort?

What aggravates your pain/discomfort?

By typing my name below, I certify that the information I provided is true, complete, and accurate. I agree to inform my therapist if any of the above information changes at any time. I understand that my massage therapist does not diagnose disease, illness, or prescribe any treatment or medication nor do they provide spinal manipulation. I understand that massage therapy is not a replacement for medical care and I will consult with a qualified physician for any physical ailments that I have. I understand that massage therapy is a therapeutic health aid and will not interpret any information given to me during the session as medical in nature.

Signature

Type your name below if you agree to the terms stated above.

Thank you!