Health History Form Name ____________________________________________   Date __________________________ Street address __________________________________________   Height/Weight ______________ _______________________________________________________   Date of birth ______________ City _______________________________________   Home phone __________________________ State and zip _________________________________   Work phone __________________________ Do you have or have you ever had any of the following conditions/illnesses/problems? Please circle Y for YES or N for NO. Be descriptive when appropriate. Heart condition: Y / N   Convulsions: Y / N   Eliminatory: Y / N High/low blood pressure: Y / N   Muscle/joint pain: Y / N   Skin: Y / N   Phlebitis: Y / N   Osteoporosis: Y / N   Digestive: Y / N   Hemophilia: Y / N   Arthritis: Y / N   Respiratory: Y / N   : Y / N   Diabetes: Y / N   Headaches: Y / N   Infectious diseases: Y / N   : Y / N   Cancer: Y / N   Circulatory: Y / N   Other: Y / N   : Y / N   Descriptions ________________________________________________________________________ ___________________________________________________________________________________ Do you wear: Contact lenses: Y / N   Dentures/removable bridgework: Y / N   Are you currently under the care of a medical doctor, chiropractor or therapist? Y / N   If yes, for what? ____________________ If no, date of last physical ___________ Allergies? Y / N   What medications have you taken in the past six months? _____________________________________ ____________________________________________________________________________________ Please describe, including dates, area of injury and treatments received: Past injuries or accidents ________________________________________________________________ Past surgeries _________________________________________________________________________ List any chronic bodily discomfort you have ________________________________________________ ____________________________________________________________________________________ Previous professional reflexology/massage/bodywork received __________________________________ Print and close this window to return to our website. You can then mail, fax or bring this form with you to your session. Mailing address: 2500 Regency Parkway Cary, NC 27511 Office: 919-481-1611 ~ Fax: 919-882-9355 Email: info@suethingtouch.com