LIVE RIGHT MASSAGE THERAPY CLINIC

Medical Health Form
NAME_______________________Phone______________________________________
ADDRESS________________________________________________________________
POSTAL CODE________________EMAIL_______________________________________
DATE OF BIRTH_______________OCCUPATION_________________________________
REFERRED BY____________________________________________________________
FAMILY DOCTOR__________________________________________________________

What is your reason for you visit today?________________________________________
Describe your current symptoms_____________________________________________
________________________________________________________________________
Date of Injury?____________________________________________________________
What aggravates it?________________________________________________________
What relieves it?__________________________________________________________
Please indicate which areas an X for pain O for numbness T for tingling

LIVE RIGHT MASSAGE THERAPY CLINIC 
Please indicate the conditions you are experiencing (X) or have experienced in the past (Y)
Musculoskeletal                                   Respiratory                                   Skin                            Other
__  bone or joint disease                                  __  breathing difficulty/asthma                __ allergies                       __ cancer 
__ tendonitis/bursitis                                       __ emphysema                                             __ rashes                         __ diabetes
__ arthritis/gout                                                __ allergies, specify                                     __ cosmetic surgery      
__ jaw pain                                                        __ sinus problems                                       __ athlete's foot              
__ lupus                                                                Nervous System                           __ herpes/cold sores    
__ spinal problems                                           __ shingles                                                  Digestive problems
__ migranes/headaches                                  __ numbness/tingling                                __ irritable bowel    
__ osteoporosis                                                __ pinched nerve                                       __ bladder/kidnes ailment
Circulatory                                          __ chronic pain                                          __ colitis                  
__ heart condition                                          __ paralysis                                                  __ crohn's disease
__ phlebitis                                                      __ multiple sclerosis                                   __ ulcers
__ high/low blood pressure                         __ parkinson's disease                              Psychological
__ lymphedema                                   Reproductive                                 __ anxiety/stress syndrome
__ thrombosis/embolism                            __ pregnant                                                 __ depression
                                                                        __ ovarian/ menstrual problems                 
Any other medical condition(s) not listed_____________________________________________
______________________________________________________________________________
List any current medications you are currently on______________________________________
______________________________________________________________________________
List past surgeries, broken bones, head injuries and plates, pins or scars _____________________________________________________________________________
______________________________________________________________________________
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