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The Health History Form

As health-care professionals, we are required to have new patients complete a health history in order to ensure we develop an accurate treatment plan.

September 27, 2012  By Andrea Collins

As health-care professionals, we are required to have new patients complete a health history in order to ensure we develop an accurate treatment plan. The basic form is determined by the province we are practising in, and samples are available on your provincial regulatory body or association websites. But, why limit yourself to these basic forms?

These forms can fulfil many functions, from obtaining additional information relating to your clients’ general health to relaying information to the patient regarding your clinic policies (including your privacy policy). You have the opportunity to customize your forms even further to include points about the business side of your practice, such as evaluating your advertising or marketing ideas.

Here are 10 ideas for customizing your health history form in order to enhance your treatments and help the business side of your practice. I have provided a copy of a health history form with each section numbered in accordance with the descriptions provided in the text. 

  1. In the name field, indicate “PLEASE PRINT.” This will help to ensure correct spelling on receipts and for files in the future.
  2. Try to have the client’s address and contact information next. This will keep the client’s personal information together in one place and make it easier for you to enter it into your accounting program or database. On your template, ensure you have a space for home, work and cellphone numbers as well as e-mail as many people have multiple contacts. Give the option for the client to indicate which they prefer as the primary contact point. Some may choose e-mail or text message while others stick to the traditional phone, but clarify which numbers they prefer or want you to avoid.
  3. The client’s date of birth field should include a day/month/year to help the client use the notation you are expecting. Asking for their date of birth will help you in a couple of ways; the first being accuracy pertaining to your treatment plans, but also for you to use for birthday cards or notifications. We rarely get birthday cards anymore and many clients appreciate the extra touch of getting a card on their birthday. It may also bring you to the front of their mind and remind them to book a massage.
  4. Depending on your provincial requirements, it may be mandatory to ask for the client’s physician’s name, address and phone number. If you are practising in British Columbia or if you deal with insurance company claims, you might want to add a section for the adjustor’s name and contact information and any other pertinent information relating to any current active file. This will help you file accurate paperwork to the correct person for their treatments without seeking out more information from them client, meaning you can get paid sooner!
  5. If you deal with clients who are frail or have medical conditions, it might be a good idea to have an emergency contact and phone number in case of a fall or other accident. You don’t want to be scrambling during an emergency trying to find out this information.
  6. Have a place for the clients to report how they found you in order to help you analyze your advertising. Be sure to include all the types of advertising that you do. Don’t forget to ask for permission to send out thank-you cards to the person who referred them.
  7. This section is good to explain to clients about confidentiality, reasons we collect health information and consent. You can also include any specific clinic policies that you have established so that the clients are made aware of them. A good example of this is your cancellation policy. Making the client aware of your policies up front will help encourage compliance in the future. This sample form does not show the privacy policy, which would be a separate sheet(s). For more information about developing a privacy policy, please see the Spring 2012 Massage Therapy Canada magazine article “Privacy Regulation in Canada” on page 30.
  8. With the introduction of privacy legislation, businesses can no longer freely contact clients with newsletters or birthday cards. Add a space on the health history form for permission to contact them in order to make your marketing more successful, if you choose to send out newsletters that help remind clients you are there and remind them to book a massage.
  9. Provide a section to allow for the tracking of the annual heatlh history updates. One idea to make this even clearer is to have different coloured pens available to allow you to track the changes to their health history over time. Remember to have a white-out tool in order to make it easier for the client to make changes to their contact information (addresses, phone numbers, etc.) – not their health history!
  10. The second page would be the section for medical conditions that you might consider including your charting for the treatment. This will help you cut down on the amount of paper for those clients you only see once.

These are only suggestions and you can choose to use some or all of these ideas. The important thing is to have tools to make our businesses run smoother and be more profitable. Business is about evolving and adapting to the current market conditions and this is one small change that could help your bottom line!

History Intake Form Numbered-1.jpg  
You can alter your provincially mandated health history form and customize it to fit you practice.  As well as giving you more information to enhance your treatments a customized health history form can help the business side of  your practice.  Shown here is a copy of page 1 of my health history form.   Page 2 would be the section for medical conditions that you might consider including your charting for the treatment.


If you would like a full copy of this form, please visit and click on the Resources section for downloads. If you are interested in having the form customized for your clinic, please contact me!

Andrea Collins has been a massage therapist since 1999. She has worked in a variety of settings, and owned her own clinic. Andrea has taught business at a private massage school and has expanded to CEU seminars in business (four-part series) and a techniques course (Massage Smarter not Harder). She will also be presenting both of these topics at the Canadian Massage Conference in October. Andrea is currently working on a business book for Canadian massage therapists that is due out this year. For more information about Andrea, please visit .

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