MASSAGE ABOVE ALL 4709 Gaetz Avenue, Red Deer, AB T4N 4A1 PHONE: 403-346-1161 CASE HISTORY FORM
GENERAL INFORMATION
Client Name:	Age:	Sex:	If ‘F’ Pregnant?
Phone (home):	Phone (work):
Address:	Postal Code:
Date of Birth:
Email Address:			Contact re: promo's/specials           (circle one)       yes       no
Occupation (present):	How long:
Occupation (previous):	How long:
Occupation Comments:
Medication: (previous & present) and why:
Present / Previous illnesses, disease, accidents:
1.	Date:
2.	Date:
3.	Date:
Diet and Exercise:
Entrance Complaint: (date of onset, cause, constant or intermittent, does pain spread, type of pain)
Aggravating Factors:
Alleviating Factors:
EXAMINATION METHOD AND FINDINGS
TREATMENT APPROACH INDICATED
Confer with M.D. (or)	Phone:		Mail:
Refer to:	Phone:		Mail:
Signature:
Where did you first hear about our clinic?
(Please be specific: e.g. article, name of friend, name of doctor, etc.)
What brings you in for a massage?

Health History: Please check the conditions that you experience frequently:
Head / Neck:	Skin:	Digestive:
Headaches	Sensitive skin	Poor appetite
Type:	Rashes / eruptions	Constipation / diarrhea
Vision problems	Cold sores	Liver / gall bladder
Contact lenses	Herpes	Excessive appetite
Earaches	Contagious condition	Difficult digestion
Sinus	Bruise easily	Pain
Allergies		Alcohol consumption
Frequent colds	Women:	heavy light
Neck pain	Menstruation	Nausea
	Painful	Gas
Respiratory:	Heavy
Chronic cough	Scant	Uro / Genital:
Shortness of breath	PMS	Frequent urination
Congestion	IUD	Kidney / bladder
Smoking	Number of children	Diabetes
heavy light	Menopause
Cardiovascular:	Pregnant	Current medications and
High blood pressure		condition treated:
Low blood pressure	Muscles / Joints:
Poor circulation	Pain
Phlebitis	Stiffness
Pain	Limitation of movement
Dizziness	Osteo arthritis:
Heart disease	Poor posture
Shortness of breath	Back pain	Surgery / Injury:
Varicose veins	Shoulder pain	Type:
Dr. diagnosed?	Other:	Date:
	Date diagnosed:	Current symptoms:
	Affected areas:
Other Health Care:
Other medical conditions: L.E. nervousness / depression
Chiropractic:	Physiotherapy:	Previous Massage Exp.:
Yes No	Yes No	Yes No
		Good Sleeping Patterns:
Other:		Yes No
		Regular exercise:
		Yes No
OR SPECIAL NOTE: (pins, wires, artificial joints or limbs, special		Regular eating habits:
equipment such as wheelchair, walker, cane, etc.)		Yes No
Yes No
NOTE: The customer warrants, represents and agrees that they know of no reason massage should not be performed, which would be detrimental to the customer or therapist. I am aware and understand I may be required to disrobe in order to receive massage therapy. Signature: Date: