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Health History Form

A complete and accurate health history is very important to ensure that massage therapy is safe for you to receive. Your treatment will continue on the assumption that you have provided an accurate health history. You can download your form, print it off and give it to Kelly when he arrives or you can fill out the interactive form below and hit Submit button and it will be emailed directly to Evolution Massage Therapy's inbox and will be reviewed before your appointment. All information obtained on this form will be kept confidential. Massage Therapy is safe for all to receive depending on your health status. Massage is also recommended for all ages but if you are under 16 years of age, your Health History Form needs to be signed by a parent or guardian, in Kelly Carrington's presence. Parental/Guardian consent must be granted in order for you to receive your massage treatment.

Download and print Health History Form

Fields in bold are required.

First Name
Last Name
Occupation
Date Of Birth	January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Contact Email
Contact Phone Number
Please check any and all health conditions that you may be currently experiencing or have experienced in the past:
Headaches
Type of Headache
Frequency
Earaches
Sinusitis
TMJ
Chronic Cough
Shortness of breath
Asthma
Smoker
# of cigarettes/day
Crohn's
IBS
Constipation(chronic or occassional)
Liver disorder
Gallbladder disorder
Kidney disorder
Bladder disorder
Bowel concerns
High Blood pressure
Low Blood pressure
Poor circulation
Heart disease
Type
Pacemaker
Haemophilia
Phlebitis
Atherosclerosis
Varicose veins
Location
Osteoarthritis
Area(s)
Rheumatoid arthritis
Spinal disc injury
Spinal Level (if known)
Spinal disc disease
Type
Scoliosis
Osteoporosis
Back pain
Location and Type
Eczema
Psoriasis
Allergies / Sensitivites
To What?
Diabetes
Type One or Two
Hypoglycemia
Epilepsy
Cancer
When/Type/Location/Treatment
Fibromyalgia
Insomnia
Chronic or occasional
Hepititis
Type
Hiv
Aids
Prosthetics/pins/plates
Type and Location
Pregnant
Due Date
Menstral Problems
Birth control pill
Depression
Anxiety
Claustophobia
Any other Health concerns not listed
Motor Vehicle Accidents
Dates/Injuries Sustained/Treatment
Surgery
Type/Date
Current Medications and conditions being treated
Physically active
Types of Exercise
Stresses in life
Signature and Date: (This area will be filled out when Kelly Carrington arrives for your service)