Health History Form

Offering Mental & Health Wellness Retreats Globally

Heal Mind, Body and Soul

Health History Form

Before proceeding with a registered massage therapy appointment, your therapist will need to review your health history in order to ensure that your treatments are safe and beneficial. To save time on your first appointment, complete this form in full. If you elect not to complete the form before you arrive, your therapist will require that you complete it at the beginning of your appointment.

Full Name*

Birth Date

Home Phone

Email Address

Full Home Address *

Date Selector*

Reason for Treatment:*

Cardiovascular Issues:*

High Blood Pressure: Low Blood Pressure: Congenital Heart Failure: Heart Attack: Phlebitis / Varicose Veins: Stroke / CVA: Pacemaker: Heart Disease:

Respiratory Issues:*

Chronic Cough: Shortness of Breath: Bronchitis: Asthma: Emphysema:

Infections*

Hepatitis: Skin Infections: TB: HIV: Herpes:

Head and Neck Issues*

History of headaches: History of migraines: Vision Problems: Vision Loss: Ear Problems: Hearing Loss:

Women only*

Are you pregnant?

Other Conditions *

Loss of Sensation: Diabetes: Allergies: Epilepsy: Cancer:

Physician*

Primary Care Physician and Address?

Other Care Professional:*

What are they treating?

Artificial Joints:*

Do you have any artificial joints? If yes, where?

Internal Pins or Wires:*

Do you have any Internal Pins or Wires? if yes, where?

Medication:*

Please list any medications you may be taking and any potential side effects.

Injuries*

Please list any injuries you have endured, from birth until the current day.

Surgeries *

Please list any surgeries you have undergone, from birth until the current day.

Other information:

Is there any other relevant information, concern or diagnosis?

Service Date*

Select massage day

Time of Service*

Select time for your massage

Do you have allergies? If yes, list all. *

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Thank you for completing your Health History Form successfully.

When you have finished completing the form, use the Submit Health History button to send your information to Ladies Retreat Spa.