Massage therapy Case history form Thank you for taking the time to fill out this form before your treatment. First Name *Last Name *Email Address *Phone *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabweDate of Birth *First time for massage therapy? *YesNoPrimary health care professional *Reason for massage treatment *HEALTH HISTORY: Please indicate conditions you are experiencing or have experiencedneckshoulderupper backmid backlow backarmslegskneeshipotherSOFT TISSUE/JOINTS (specify its nature i.e. pain, sti ness, numbness, etc.)HEADACHEStensionmigrainestooth/jaw/ear painhead traumaACCIDENT/INJURYcar accidentwork relatedaccident/injury detailsRESPIRATORYchronic coughshortness of breathbronchitisasthmaemphysemapneumoniasinus problemsrespiratory detailsCARDIOVASCULARhigh blood pressurelow blood pressureheart attackphlebitisstroke/CVApacemakerheart diseaseanginachronic congestive heart failurecardiovascular detailsINFECTIOUS DISEASEhepatitistuberculosisHIVCOVID-19otherinfectious disease detailsWOMENpregnantPregnancy due dateSKINskin condtionbruise easilyherpesvaricose veinsathletes footloss of sensationskin condition detailsOTHER CONDITIONSneurological conditionsepilepsydiabetes/note onsetallergies/anaphylaxis?cancerarthritis/ note typevision losshearing lossconstipationinsomniahaemophiliakidney/bladder problemsotherother conditions detailsSURGERYtype date current symptomsCURRENT MEDICATIONS AND CONDITIONSPINS/WIRES/PROSTHETICSPRESENT INVOLVEMENT IN OTHER HEALTH CAREyesnoIf yes, specifyI have read the above information and have stated all my previous and current medical conditions. I take it upon myself to update the massage therapist regarding any changes in my condition. I understand that all massage treatments will be discussed and planned with the massage therapist, and will require my informed consent. *Submit Case History Form
