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:
- Client details
- date of birth
- contact number/ email
- Date on which Health History was taken or updated
- General health status
- Name, address, and contact number of primary care physician
- Primary complaint
- Location and nature of soft tissue and or joint discomfort
- Infectious/ contagious skin conditions (for example: impetigo, fungal infections, athlete’s foot, molluscum contagiosum, scabies, ringworm, shingles…)
- Infectious/ contagious respiratory conditions (for example: coronavirus, diptheria, flu, measles, mumps, rubella, MERS, SARS, whooping cough…)
- Current involvement in treatment with other health care practitioner(s)
- Current medication(s) and condition(s) they are treating
- History of injuries or accidents (nature and timing)
- History of surgical procedures (nature and timing)
- History of massage therapy
- Vision or hearing loss/ loss of sensation
- Possible cardiovascular insufficiency, for example:
- high blood pressure
- low blood pressure
- chronic congestive heart failure
- heart disease
- history of myocardial infarction
- Family history of cardiovascular difficulties
- Presence of pacemaker or similar device
- Possible respiratory insufficiency, for example:
- chronic cough
- shortness of breath
- Family history of respiratory difficulties
- Known allergies or hypersensitivity reactions
- Phlebitis / varicose veins
- History of cerebro-vascular accident
- Family history of arthritis
- Pregnancy, gynaecological conditions
- Other diagnosed diseases or medical conditions, for example: digestive conditions, haemophilia, osteoporosis, mental illness etc.
- 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?
- Have you ever had any serious illness(es)?
- Any other residual effects/ problems?
- Have you ever been hospitalized?
- 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
- 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
- What is your occupation? Describe your activities at work. Hours (e.g. prolonged sitting)?
- 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