Health History: Please check the conditions you are currently experiencing, or have experienced often in the past.

Have you ever had a motor vehicle accident? yes no            Date:
Do you have children? yes no            Ages:
What brings you in for a massage? ___________________________________________________________

Head/Neck current previous headaches, type: vision problems contact lenses earaches Muscles/Joints pain or stiffness in left or right current previous neck: L R low back: L R mid back: L R upper back: L R shoulders: L R leg: L R knee: L R hand/wrist: L R other: Respiratory current previous chronic cough shortness of breath smoking breathing problems other: Cardiovascular current previous high blood pressure low blood pressure poor circulation heart disease phlebitis stroke

Other Conditions current previous difficult digestion constipation liver gall bladder kidney bladder diabetes, onset sinus allergies insomnia cancer arthritis Infections current previous herpes hepatitis plantar warts TB HIV/ AIDS other: Skin current previous skin conditions: bruise easily Other Healthcare Medical Doctor Rehabilitation Massage Other:

Women current previous menstrual problems caesarian, or other gynecological surgery pregnant; due: menopausal problems Special Notes (Pins, wires, artificial joints/limbs, gait aides) Surgery date: Dr. diagnosed? affected areas: current symptoms Injury type: date: current symptoms: Other Medical Conditions Current Medications name: for what condition?

I understand that the information on this form will be confidential and will be used for no other purpose than the clinical records of The Sports Rehabilitation Institute. The information given by me on this form is accurate to the best of my knowledge and I understand that it will be used by the registered massage therapist in the determination of treatment which is appropriate form. It is my responsibility to update this information as it changes, I am free of all contagious and infectious diseases. I understand that if I do not give 24 hours notice of cancellation of any appointment, I will be charged in full for a missed appointment .

Signature: _______________________________________ Date: ________________