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If you haven't seen Jennifer since before January 1, 2022

Please fill out this Health History and submit. All clients must fill out a Health History prior to their first massage. This will save time that may take up your appointment time during your first visit.

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Health History Form

An accurate health history is important to ensure that it is safe for you to receive massage therapy. If your health status chances in the future, please let me know. All information gathered for this treatment is confidential except as required or allowed by law or except to facilitate diagnosis (assessment) or treatment. You will be asked to provide written authorization for release of any information. For full details, please read our Privacy Policy.

Contact Information:

Input your name

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Your current address

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type your postal code

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type your date of birth

Your current address

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Medical History:

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How do you rate your General Health?

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Please check off any conditions you are experiencing or have experienced

Respiratory:

Is there a family history of any of the above?

Cardiovascular:

Is there a family history of any of the above?

Neck / Head:

Infections:

Other Conditions

Is there a family history of Arthitis?

Soft Tissue or Joint Discomfort

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Surgeries or Injuries

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Of Special Note:

Are you currently or previously seeing:

Other Medicial Conditions not listed above:

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