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Institute of Natural Therapies - Student Health Questionnaire

P.O. Box 222
Hancock, MI 49930

This will be used as a guideline and will remain confidential except if the class needs to know specific contraindications for massage therapy

Name _______________________________________________ Today’s Date____________________________

Weight ________________ Height ________________ Birth date _____________________________

Do you have, or have you been informed of, any of the following conditions or health problems?

(Please write the answer “yes” or “no”)

Circulatory disorders	______	Mental disorders	______	Thyroid problems	______
Blood clots	______	Neurological disorder	______	Carpal Tunnel	______
Thrombosis	______	Numbing/tingling	______	Hand/wrist pain	______
Phlebitis	______	Loss of sensation	______	Digestive problems	______
Varicose veins	______	Memory loss	______	Respiratory problems	______
Heart disease	______	Learning disorder	______	Low back pain	______
High blood pressure	______	Hallucination	______	Spinal pain	______
Low blood pressure	______	Visual disorder	______	Diabetes	______
Dizzy spells	______	Trembling	______	Stroke	______
Arthritis	______	Audio disturbance	______	Skin irritations	______
Osteoporosis	______	Closed head injury	______

Please list any medications you are currently using. ___________________________________________________

Are you presently under the care of a medical physician/chiropractor/therapist?        Yes              No

If yes, please explain___________________________________________________________________________

Are you receiving care from a psychologist, social worker/counselor? If yes, please explain _____________________

Do you have chronic body discomfort? If yes, please explain_____________________________________________

Past accidents, injuries, broken bones, or surgeries?__________________________________________________

What are your current exercise programs, and/or special diet? ___________________________________________

Do you use alcohol, tobacco, or caffeine? If yes, please specify. __________________________________________

I certify the above information is true:

Signature: ____________________________________________________     Date: ________________________