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.

High Blood Pressure: Low Blood Pressure: Congenital Heart Failure: Heart Attack: Phlebitis / Varicose Veins: Stroke / CVA: Pacemaker: Heart Disease:
Chronic Cough: Shortness of Breath: Bronchitis: Asthma: Emphysema:
Hepatitis: Skin Infections: TB: HIV: Herpes:
History of headaches: History of migraines: Vision Problems: Vision Loss: Ear Problems: Hearing Loss:
Are you pregnant?
Loss of Sensation: Diabetes: Allergies: Epilepsy: Cancer:
Primary Care Physician and Address?
What are they treating?
Do you have any artificial joints? If yes, where?
Do you have any Internal Pins or Wires? if yes, where?
Please list any medications you may be taking and any potential side effects.
Please list any injuries you have endured, from birth until the current day.
Please list any surgeries you have undergone, from birth until the current day.
Is there any other relevant information, concern or diagnosis?
Select massage day
Select time for your massage
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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.