Medical History Form

Please complete this brief medical history form, prior to your session with Kate Bruecker, LMT.
All forms will be kept confidential and used only by the practitioner in regards to your massage session.

If you have any questions regarding the information on this form, please don't hesitate to reach out. We'll gladly guide you through, or explain why we might be asking for particular information prior to your service with us. Your health and safety is our top priority!
Your information will be kept confidential and never shared.

Massage Therapy - Health History Form

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Primary Care Physician & Phone Number *

What is your occupation or what posture do you assume most of the day? *

What is your reason for choosing massage & what results do you expect from massage therapy? *

Phone Number *

Date of Birth *

Were You Referred to Massage by a Physician? *

Yes No

Do we have permission to contact your physician should the need arise? *

Yes No

Do you take medications? Please state for what medical condition. *

Have you had a COVID-19 Vaccination or Booster shot within the last 14 days? *

Yes No

Email *

Would You Like to be Included in our Studio Newsletter Sent via Email? *

Yes! Sign Me Up! No thanks!

Have you previously received a professional massage? *

Yes No

What was the approximate date of your last professional massage? *

Please tell us where you have pain, discomfort and/or where you hold your tension. *

Please indicate below if you suffer from any of these medical conditions: *

Skin Condition: Allergies, acne, rash, skin cancer, fungal infections or other Recent Injury: Whiplash, sprain, deep bruise, fracture, dislocation or other Musculoskeletal Conditions: Joint problems, bone conditions, vertebral disc problems - Please list location to right Neurological Conditions: Sciatica, numbness, tingling of any area, stroke, epilepsy, MS, neuropathy, headaches or other Circulatory Conditions: Heart disease, phlebitis, aneurysm, atheroschlerosis, arrhythmia, blood pressure issues, diabetes, other Lymph/Immune System Conditions: Swollen glands, lymphoma, other Are you pregnant? Please list how many weeks and/or any complications to right. Previous Surgery? Please list type and date to right. Please list to the right any other conditions not mentioned above.

Please list any information from the conditions to the left here. *

Please share any other information you would like us to have or submit any questions here and we'll be sure to get back to you ASAP. *

Submit

Sheer Blue Artistry & Wellness

PO Box 559 (Mailing)
Fremont, WI 54940

sheerblueaw.com
920.915.9286 - Text Friendly!
[email protected]