Health History / Cancellation Form

Ability Massage Therapy & Acupuncture Studio Confidential Health History Form
A complete health history form is essential to your massage therapist. This will ensure that it
is safe for you to receive a massage therapy treatment. If your health status or personal
information changes please let us know. All information gathered for this treatment is
confidential, unless otherwise deemed by law, to facilitate a diagnosis or treatment plan. If
this should occur then your permission (written) will be requested prior to release of
information. Health history forms must be updated yearly.
Name:______________________________________________________
_Date:___________________
Address:____________________________________________________________________________
Postal Code:_________________Date of Birth:_________________Occupation:___________________
Home Phone:_________________Cell Phone:________________Work Phone:____________________
Email:__________________________________Extra Curricular Activities:________________________
What brings you in today?_______________________________________________________________
When did it start?__________________________Have you seen a doctor for this?__________________
What makes it better?_________________________Worse?___________________________________
When was your last massage therapy treatment?_____________________________________________
Have you had or are you currently having any of the following conditions? Please mark with a ___
Please indicate your family history of the following conditions with an X
Respiratory
__chronic cough
__shortness of breath
__bronchitis
__asthma
__emphysema
__tuberculosis
Other
__loss of sensation/numbness
__diabetes
__allergies
__epilepsy
__cancer
__osteoporosis
__digestive conditions
Cardiovascular
__high/low blood pressure
__heart attack
__phlebitis
__stroke
__pacemaker
__heart disease
__congestive heart failure
__blood conditions
__bruise easily
Head/Neck
__vision problems
__ear/hearing problems
__headaches
__migraines
__whiplash/conditions
__Pregnant?____________
Infections
__hepatitis
__HIV
__herpes
__other______________________
Soft Tissue/Joint Problems
__neck
__TMJ/jaw
__low back
__mid back
__upper back
__shoulders
__arms/hands
__hips
__legs/knees/feet
__arthritis
__pins / wires /artificial joints
__other________________
_________________________
Skin Conditions
__execema________________
__psorasis________________
__warts___________________
__melanoma_______________
__allergies_________________
List current medications:________________________________________________________________
Herbal Supplements:__________________________________________________________________
List all surgeries and dates:_____________________________________________________________
Medical Doctor Name:____________________________Phone #______________________________
Address:_____________________________________________Postal Code:_____________________
Are you currently seeing: Chiropractor_____Physiotherapist___Naturopath___Acupuncturist___
Nutritionist___Personal Trainer___Yoga___Pilates___
How did you find us? Road Signage:___Website:___Postcard:___Newspaper:___Social Media:___
Sporting Event:___Community Event:___Referral:_____________________Walk In___Other:_________
Ability Massage Therapy & Acupuncture Studio
Cancellation Policy
Your therapist has set aside an appointment time just for you. Please respect their
time.
Missed Appointments $40
Cancelled Appointments with less than 12 business hours notice $20
Late arrivals will be billed for the full appointment time. (If we have time to offer you
your full treatment length we will gladly do so.)
You can always send a friend in your place!
We understand that life happens and sometimes you just can’t keep your appointment.
Hopefully we can fill the appointment time with another client and you will not be billed.
We allow everyone 1 freebie.
Thanks for your understanding.
Rose Murdoch - Owner
I____________________________________________accept these terms.
(print name)
Date:_____________________ Signature:____________________________