Health History Form

If you are a new client to Blackbird Wellness VT, we please ask that you fill out this form prior to your first treatment. You may also print this form and hand deliver at time of appointment.

Name *

Name

First Name

Last Name

Email Address *

Mailing Address *

Phone

Emergency Contact *

Name and phone

Date of Birth *

MM-DD-YYYY

Primary Physician

Name and phone

Medications or allergies

If yes, please list

Have you ever received professional massage before? If yes, when was your last treatment?

What results do you expect from treatment?

Is there a specific ailment that you would like the therapist to address?

What are your current exercise habits?

Sleep Habits

Please select one that best describes

Poor (very little sleep wake regularly 1-4hrs)

Average (moderate sleep wake sometimes 5-7hrs)

Great (sleep soundly and undisturbed 8+hrs)

Please describe any medical conditions you have

Massage can be contraindicated for some medical conditions, please always consult with your primary care physician prior to treatments if you are unsure.

Signature

By signing below you are confirming the information you recorded is best to your knowledge, and that you have consulted with your physician to be cleared if you have any medical conditions or issues that may be contraindicated for massage.

Date

YYYY

Health History Form

Let’s stay in touch!

(802) 730.0630 • 92 Lower Main St. morrisville, VT 05661