Online Health History and Consent Form

Gender:

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Receive Text Messages:

Health History: Please indicate conditions you are experiencing, past or present. 

ACCIDENT/INJURY 

CARDIOVASCULAR

REPRODUCTIVE

GASTROINTESTINAL

HEADACHES

INFECTIOUS DISEASE

SURGERY

SOFT TISSUE/ JOINT & BONE:

AREAS WITH ACUTE OR CHRONIC PROBLEMS

SKIN

RESPIRATORY

OTHER CONDITIONS:

MEDICATIONS & SUBSTANCE USE

Health History and Treatment Consent

I acknowledge and understand that the massage therapist must be fully aware of my existing medical conditions. I have completed my medical history form as provided and disclosed to the massage therapist all my medical conditions. I understand that it is my responsibility to keep the massage therapist updated on my medical history. The information provided is true and complete to the best of my knowledge. I consent to be assessed by my massage therapist, using a variety of examinations and techniques, for the conditions noted in my health history.  I have read the above consent and I have had an opportunity to ask questions about my massage therapy assessment. I understand that I may withdraw my consent to assessment at any time and that the assessment will be stopped. By clicking   "I agree" on this form, I confirm my consent to assessment & massage treatment and Intend this consent to cover the assessment & massage treatment discussed. I understand that all information gathering is confidential and that I must give consent for my health records to be released.

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Josh Sapieha

Massage Therapy

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