oY Happy Famih 1081 ats t, ern lL ON L4C 972 aC (apoy Far Teh 905-737-5559, rox 905-737-5556 eliness Clic sent Health Hstory Form vr HappyFamiyelness ca "An accurate heath history Is important to ensure that es safe Tor you to receive a massage Weatment_ All information gathered for this {reatment is confidential except as required or allowed by law, Written authorization will be required for release of any information 24 hour cancellation notices required or a missed appointment fe will be charged. ‘Name Ema! Home). Work) cati Address cay Postal Code Date ofbith:_f-_J-___ Occupation: First time for Massage Therapy: YES/NO Family Physician; Adres: ‘Who can we thank for referring you here? InDoctor— Adres: Reason for Massage Therapy Treatment: Indicate pain and/or stftness by shading in the area — Indicate numbness andlor tingling with an °N’ or “T™ Health History: Please check spaces below for any conditions that you are experiencing or have experienced Soft TissuelJoints Respiratory ‘Skin tendonitis / bursitis chronic cough 1» skin condition weakness 1B shortness of breath bruise easily sprains strains 1D bronchitis D herpes arthritis OA RA other 1D asthma varicose veins Tocation emphysema athletes foot OD heriated dies pneumonia warts plantar wars Q_Sinus problems loss of sensation Headaches tension headaches Cardiovascular Other Conditions migraines 1D igh blood pressure neurological conditions tooth jaw’ ear pain (circle) Dow blood pressuze epilepsy Dead trauma — date: Dear attack Ddiabetes-onset: phlebitis allergies - anaphylaxis ¥7N Accident /Injury stroke CVA cancer Dear accident 1D pacemaker vision problems D whiplash | 1D beat disease Dearing loss or tints date D angina 2 constipation symptoms 1D chronic congestive heat failure other digestive conditions: physica imitations —______ nections nisease 'Dinsomnia poor sleeping pattems aD fractres 1D hepatitis kidney / bladder problems tuberculosis haemophilia Women 1B HIV/AIDS 2 fibromyalgia pregnant - due date: Other: 2 osteoporosis gynaecological conditions surgical implants (pins, plates, etc) Surgery Current Medications & Conditions Present Involvement in Other ‘Type: Healtheare: YES/NO Date: IT Yes Specity ‘Curent sympioms ‘General Health Status: excellent / good ! fair / poor Family History of Arthritis? Yes / No have read the above information and have stated all my previous medical conditions. I take it upon myself to update the massage ‘therapist regarding any changes in my condition, T understand that all massage treatments will be discussed and planned with the massage therapist, and will required my informed consent Signature: Date: