HEALTH HISTORY FORM

An accurate health history is important to ensure that it is safe for you to receive massage. If your health status changes in the future, please let
us know. All the information is gathered and is confidential except as required by law. You will be asked for written consent for release of any
information.

Name: _Neil Manisce_ ___ M■F□ Date: __November 1st, 2010___

Address: __123 Tibial Avenue________ Midland, Ontario____________L9M 1R3 ________

Street City Postal Code

Phone (Home): ___123-4567 _____ Phone (Work):_______876-1122 ____________

Email Address: _nmanisce@ibew.on.ca ______ DOB (mm/dd/yy): ____September 22, 1983______
Occupation: ____Electrician_______ Primary Complaint: ___right knee, meniscus____
Contact in case of emergency: ______Poppy Lydial_______ Relation: ___Wife______
Phone Number: ____123-4567_______

Respiratory Skin Women

□ Chronic Cough □ Rashes □ Pregnant (due: __________)
□ Shortness of Breath □ Athletes Foot □ Gynaecological Conditions
□ Bronchitis □ Warts □ Menopause
□ Asthma □ Other: ______________ Soft Tissue/Joint Discomfort
□ Emphysema Other Conditions □ Head __________________
□ Sinus Infection □ Loss of Sensation
Cardiovascular □ Diabetes: Type _____ □ Neck __________________
□ High Blood Pressure □ Allergies
□ Low Back ______________
□ Low Blood Pressure □ Epilepsy
□ CCHF □ Arthritis □ Mid Back ______________
□ Heart Attack/MI □ Cancer
□ Varicose Veins □ Fibromyalgia □ Upper Back ____________
□ Phlebitis □ Urinary Disorders
□ Stroke/CVA □ Kidney Disorders ■Shoulders L R _sore______
□ Pacemaker/Similar □ Digestive Disorders
■Arms L R sore from crutches
□ Poor Circulation □ Liver
Infection
□ Hernia ■ Legs L R _tired and sore_
□ Hepatitis Head/Neck
□ TB □ Vision Problems ■ Knees L R Meniscal surgery
□ HIV □ Ear Problem/pain □ Other: __________________
□ Infectious conditions □ Hearing Loss