HEALTH HISTORY QUESTIONNAIRE All questions contained in this questionnaire are optional and will be kept strictly confidential
PATIENT INFORMATION First Name:
Marital status (circle one) Single / Mar / Div / Sep / Wid
Date last seen:
Relationship to patient:
Chose clinic because/Referred to clinic by: Family
Close to home/work
CHIEF HEALTH CONCERN What health concern(s) are you seeking treatment for?
Have you ever been diagnosed with the following?
Mental health issues
Allergies. Please list:
Please list any surgeries you have had: Please list any prescription medication you are taking:
MUSCULO-SKELETAL PROBLEMS Please circle problem areas
What kind of pressure do you prefer?
What are your goals for receiving massage
How long ago did pain appear?
Is the problem related to an injury?
Nature of pain
Comes and goes
With certain movements
Other treatments received
HEALTH HABITS AND LIFESTYLE Exercise
What type of exercise do you get? How frequently do you exercise? Irregular mild exercise
Irregular vigorous exercise
Regular mild exercise
Regular vigorous exercise
What is the nature of your work? Mark all that apply Sedentary
Rank stress levels:
Consent to treat: I understand the basic purpose of massage therapy is relaxation and relief of muscle tension and pain. If I experience any pain or discomfort during this and any following sessions, I will immediately inform Jennifer so that the pressure and/or strokes can be adjusted to my level of comfort. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in the termination of the session and I will be liable for the payment of the session.
Office Policies: I understand that Jade Spring Acupuncture & Massage will use my email address to confirm appointments and send a monthly newsletter. Further, I understand that the organization will never sell my contact information, or “spam” my email account and that at any time I have the right to request to be taken off of the organization’s mailing list. I have been notified that Jade Spring Acupuncture & Massage has a 24 hour cancellation policy. In the event that I miss an appointment without notifying Jennifer Stevenson, or cancel without due notice, I may be charged 40% of the cost of the scheduled appointment.
Patient or Guardian Name