Massage Client Health History Questions & Intake Forms

Minimum Required Information

Health history information must be asked from the client in order to identify indications and/or
contraindications to massage treatment. At the minimum, information requested from the massage client must include:

1.  Client details
   • name
   • address
   • date of birth
   • contact number/ email
   • occupation
2.  Date on which Health History was taken or updated
3. General health status
4. Name, address, and contact number of primary care physician
5. Primary complaint
6. Location and nature of soft tissue and or joint discomfort
7. Infectious/ contagious skin conditions (for example: impetigo, fungal infections, athlete’s foot, molluscum contagiosum, scabies, ringworm, shingles…)
8. Infectious/ contagious respiratory conditions (for example: coronavirus, diptheria, flu, measles, mumps, rubella, MERS, SARS, whooping cough…)
9. Current involvement in treatment with other health care practitioner(s)
10. Current medication(s) and condition(s) they are treating
11. History of injuries or accidents (nature and timing)
12. History of surgical procedures (nature and timing)
13. History of massage therapy
14. Vision or hearing loss/ loss of sensation
15. Possible cardiovascular insufficiency, for example:
    • high blood pressure
    • low blood pressure
    • chronic congestive heart failure
    • heart disease
    • history of myocardial infarction
16. Family history of cardiovascular difficulties
17. Presence of pacemaker or similar device
18. Possible respiratory insufficiency, for example:
    • chronic cough
    • bronchitis
    • shortness of breath
    • asthma
    • emphysema
19. Family history of respiratory difficulties
20. Known allergies or hypersensitivity reactions
21. Phlebitis / varicose veins
22. History of cerebro-vascular accident
23. Diabetes
24. Cancer
25. Epilepsy
26. Arthritis
27. Family history of arthritis
28. Hepatitis
29. HIV
30. Herpes
31. Pregnancy, gynaecological conditions
32. Other diagnosed diseases or medical conditions, for example: digestive conditions, haemophilia, osteoporosis, mental illness etc.
33. History of headaches or migraines

Health History Sample Follow Up Questions

General Trauma, Accidents, Injury

• How did the accident happen? What happened to you in the accident?
• Have you experienced any physical trauma that required treatment or should have been treated?
• Were there any residual problems or prolonged side effects?
• What treatments did you receive in relation to the injuries you suffered from the accident?

Serious Illness 

• Have you ever had any serious illness(es)?
• Any other residual effects/ problems?
• Have you ever been hospitalized?

Medications 

• Is your medication prescribed or over the counter?
• What does your medication treat?
• How long have you been taking and how often do you take your medication?
• Do you take any vitamins?
• E.g., Steroids, antidepressants, NSAIDs, antibiotics, hormones

Allergies 

• Do you have any allergies? Food, meds, seasonal, What happens to you when you get an allergic reaction to them?

Prior Care / Treatment with other Healthcare Practitioners

• Describe the care. Did it help?
• What has & has not worked previously

 Occupation 

• What is your occupation? Describe your activities at work. Hours (e.g. prolonged sitting)?

Exercise 

• Describe your overall fitness level.
• Do you participate in regular exercise? (describe type, intensity & frequency)

Sample Health History Forms

SAMPLE Massage Health History Form from the College of Massage Therapists of Ontario (CMTO): https://www.cmto.com/assets/Health-History-Form-.pdf

Sample Massage Therapy Intake Form Alberta: https://www.ualberta.ca/glen-sather-clinic/patient-resources/massage-therapy-intake-form.pdf

Page 9 of the following pdf document, College of Massage Therapists of Prince Edward Island RMT Standards of Practice: Obtain, Update and Record Client’s Health History https://www.cmtpei.ca/sitefiles/Documents/CMTPEI-Standards-of-Practice_2019-02-03.pdf

Page 11 of the following document, College of Massage Therapists of Newfoundland & Labrador RMT Standards of Practice https://nlmta.ca/wp-content/themes/nlmta/docs/Standards-of-Practice.pdf

Page 11 of the following document, College of Massage Therapists of New Brunswick RMT Standards of Practice https://www.cmtnb.ca/docs/Standards-of-Practice-NBjuly2016.REV_.pdf