Confidential Health Information Form

940 Town Centre Drive Suite B

Medford OR 97504

First Name

Last Name

Street Address

City

State

Zip Code

Birth Date

Occupation

Home/Cell Phone

Work Phone

Physician

Emergency Contact Name

Emergency Phone

Please answer the following questions:

Have you ever had a professional massage?

Yes

What other ways do you relieve stress?

Do you exercise regularly or participate in any sports?

Yes

If yes, what kind and how often?

Are you currently under the care of a physician or other health care provider for a specific condition?

Yes

If yes, please specify:

Do you take any medication (including asprin or ibuprofen)?

Yes

If yes, list medication, dosage, and condition.

Do you have skin problems or allergies?

Yes

If yes, please describe:

Have you ever had surgery?

Yes

If yes, please describe:

Do you have, or have you ever had cancer?

Yes

If yes, please describe:

Do you have, or have you ever had heart problems?

Yes

If yes, please describe:

Do you have HIGH or LOW blood pressure?

HIGH blood pressure

LOW blood pressure

Do you have varicose veins, blood clots, or any other circulatory problems?

Yes

If yes, please describe:

Do you have diabetes?

Yes

If yes, how is it controlled?

Do you have arthritis?

Yes

If yes, which type of arthritis?

Osteoarthritis Rheumatoid Arthritis

If yes, where is the arthritis located?

Do you have spinal problems?

Yes

If yes, please describe:

Do you experience prolonged episodes of depression or other emotions?

Yes

Do you have an infectious or contagious disease?

Yes

If yes, please describe:

Are you experiencing sleep disorders at this time?

Yes

Are you pregnant?

Yes

If you are pregnant, what stage?

Do you wear contact lenses and if so, are they hard or soft?

I do not wear contact lenses.

I wear soft contacts

I wear hard contacts

Do you wear dentures?

Yes

Do you wear hearing aids?

Yes

Do you have any needs that require special attention?

Yes

If yes, please specify:

Before receiving your massage, is there any other medical condition I should be aware of?

Yes

If yes, please describe:

Do you want specific results from your massage?

Yes

If yes, please describe:

I understand that massage practitioners do not diagnose illness, disease, or other physical or mental disorders. Massage practitioners do not prescribe medical treatment or pharmaceuticals. It has been made clear to me that massage is not a substitute for medical examination or diagnosis and that it is recommended that I see a physician for any physical ailment that I might have. I have stated all my known medical conditions and take it upon myself to keep the massage practitioner updated on my physical health.

Signature Box

By typing your name in this box you agree to the above declaration

Date Signed

After you click on the submit button below, you will be returned to this page where you can click here to return to the PRIVATE PRACTICE FORMS page or the MEDICAL PRACTICE FORMS page to complete your forms.

Your information will be encrypted.

Confidential Health Information Form

940 Town Centre Drive Suite B

Please answer the following questions:

940 Town Centre Drive Suite B

Susannah Graven LMT