Health History

Thank you for taking the time to provide insight into your current and past health. This information helps us take proper precautions to support your safety and enhance the benefits of receiving bodywork. Everything you share with us is confidential.

Should this online form create any difficulty or if you have access needs, please contact your massage therapist directly and they will support gathering this information another way.

Please complete the form below:

Name

First Name

Last Name

Pronouns

(Included in online profile)

Phone

(###)

###

####

Email

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date Of Birth

MM

DD

YYYY

Tell us about any identities that are important to you (i.e. gender, racial, cultural, or ethnic, religious, roles, or other):

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

####