Serendipity Wellness Health History Form

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Please answer the following questions as honestly and thoroughly as possible. Your answers help us prepare for your appointment, in order to provide to the best service and safety possible.

Please review our Appointment Policies and Informed Consent Information here:
https://forms.gle/f7NxLJJdH4G8YX1Z6

By submitting this form you agree to the following:
It is your choice to receive massage therapy. You are aware of the benefits and risks of massage and give consent for massage.

You understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments.

You acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis.

You have stated all medical conditions that you are aware of and will inform your practitioner of any changes in your health status.

You understand that your personal health information will be collected. You understand that all information that you provide will be kept confidential unless required by law.

Treatments may be covered by extended health care plans. You understand that it is your responsibility to confirm the exact details of your coverage.

First and Last Name *

Date of Birth *

YYYY

Email Address *

Phone Number: *

Emergency Contact Name and Phone Number *

What are your goals for this session? *

Do you have any areas of discomfort in the body? *

Are you taking any medications? *

If yes, please list name and use:

Are you currently pregnant? *

If so, for how long? Any risk factors?

Have you had any orthopedic injuries? *

If yes, please explain:

Please indicate any of the following that apply to you: *

Cancer

Headaches/Migraines

Arthritis

Diabetes

Joint Replacement

High/Low Blood Pressure

Neuropathy

Fibromyalgia

Stroke

Heart Attack

Kidney Disfunction

Blood Clots

Numbness

Sprains or Strains

Other

None

Required

Please explain any condition you have marked above: *

Do you have any requests, or is there anything else I should know? *

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