HEALTH HISTORY

Please use "c=current, p=past, s=sometimes"


MUSCULO-SKELETAL
      ___bone or joint disease________________
      ___tendinitis_________________________
      ___bursitis __________________________
      ___broken/ fractured bones______________
      ___arthritis__________________________
      ___sprains/strains_____________________
      ___low back, hip, leg pain_______________
      ___neck, shoulder, arm pain_____________
      ___ headaches, head injuries______________
      ___jaw pain/TMJ_____________________
      ___lupus____________________________

CIRCULATORY
      ___heart condition____________________
      ___ varicose veins____________________
      ___blood clots_______________________
      ___high blood pressure_________________
      ___low blood pressure_________________
      ___ lymphedema______________________
      ___breathing difficulty__________________
      ___sinus problems_____________________
      ___allergies (inc. food) _________________

REPRODUCTIVE
      ___pregnant (stage)____________________
      ___PMS____________________________
SKIN
      ___allergies__________________________
      ___rashes___________________________
      ___athlete's foot ______________________
      ___warts ___________________________
      ___herpes simplex ____________________

DIGESTIVE
      ___irritable bowel syndrome _____________
      ___ constipation_______________________
      ___gas/ bloating_______________________
      ___diverticulitis_______________________

NERVOUS SYSTEM
      __sleep disorders______________________
      ___herpes/ shingles ____________________
      ___numbness/ tingling __________________
      ___chronic pain_______________________
      ___fatigue ___________________________

INFECTIOUS DISEASE
      __disease name(s)______________________
      ____________________________________
      ___cancer/ tumors______________________
      ___depression ________________________
      ___diabetes __________________________
      ___eating disorders ____________________
      ___nicotine/ caffeine use_________________
      ___ drug/ alcohol use____________________
OTHER____________________________________________________________________________

It is my choice to receive massage therapy. I realize the treatment is being given for the well-being of my body and mind. This includes stress reduction, relief from muscular tension, spasm or pain, or for increasing circulation or energy flow. I agree to communicate with my practitioner any time I feel my well-being is being compromised. I understand that massage practitioners do not diagnose illness, disease, or any physical or mental disorder; nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations. I acknowledge that massage is not a substitute for medical examination or diagnosis, and it is recommended that I see a primary care provider for that service.
I have stated all medical conditions that I am aware of and will update the massage practitioner of any changes in my health.
I agree to pay all charges incurred by receiving massage therapy in this practice. Payment is due at time of service.

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