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    Patient History Edited 2019

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    api-468186696
    This document contains a patient history form for a massage therapy clinic. It requests information such as the patient's name, address, contact details, referral source, accident/injury details, medical conditions, medications, and a pain diagram. The form authorizes the clinic to collect the patient's personal and medical information to provide treatment and contact the patient and referring doctor as needed. It also notes the clinic's 24-hour cancellation policy.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Patient History Edited 2019

    Uploaded by

    api-468186696
    58 views3 pages
    This document contains a patient history form for a massage therapy clinic. It requests information such as the patient's name, address, contact details, referral source, accident/injury details, medical conditions, medications, and a pain diagram. The form authorizes the clinic to collect the patient's personal and medical information to provide treatment and contact the patient and referring doctor as needed. It also notes the clinic's 24-hour cancellation policy.

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    patient history edited 2019

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    This document contains a patient history form for a massage therapy clinic. It requests information such as the patient's name, address, contact details, referral source, accident/injury details, medical conditions, medications, and a pain diagram. The form authorizes the clinic to collect the patient's personal and medical information to provide treatment and contact the patient and referring doctor as needed. It also notes the clinic's 24-hour cancellation policy.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    58 views3 pages

    Patient History Edited 2019

    Uploaded by

    api-468186696
    This document contains a patient history form for a massage therapy clinic. It requests information such as the patient's name, address, contact details, referral source, accident/injury details, medical conditions, medications, and a pain diagram. The form authorizes the clinic to collect the patient's personal and medical information to provide treatment and contact the patient and referring doctor as needed. It also notes the clinic's 24-hour cancellation policy.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    CONFIDENTIAL

    PATIENT HISTORY FORM


    Name Birthdate

    Address
    Phone Home Cell Work

    Email Occupation
    Family Referring
    Doctor Professional
    How did you hear about (Registered) Massage Therapy?

    How did you hear about our clinic?

    ICBC Accident Date:


    Yes No Claim#
    Related?
    If Active Claim, please inform RMT as you will need to fill out the related Claim Form
    Is the reason for your visit to our clinic, due to a work related injury? Yes No

    Do you have a WCB Claim? Yes No

    Have you ever had a WCB claim? Yes No


    Have you ever had a claim denied? Yes No
    Other Therapy/Treatment (Past or Present, DOES NOT have to be related to this visit)

    Treatment Type Date of Last Visit (Approx.) Treatment Type Date of Last Visit (Approx.)

    Massage Therapy Physiotherapy

    Chiropractor Naturopath

    Rolfing Acupuncture
    OTHER

    List any Activities, Sports, Hobbies (ie. Jogging, Hockey, Crafts, Computer, etc)

    Educate Restore Movement Improve Quality Of Life


    Please indicate if any of the following conditions apply to you: (P = Past / C = Current) Circle if necessary.

    Heart Attack Headaches / Migraines Skin Condition

    High / Low Blood Pressure Dizziness / Fainting Joint Dislocation

    Stroke or Aneurysm Nausea Bone Fracture

    Pace Maker Spinal Injury Arthritis

    Other Heart Condition Head Injury Osteoporosis


    Epilepsy / Other
    Varicose Veins Rods / Pins / Plates / Shunts
    Seizures
    Other Neurological
    Bruise Easily Implants
    Condition
    Other Circulatory Condition Asthma Transplant

    Diabetes Chronic Sinusitis Corrective Lenses / Contacts


    Other Respiratory
    Kidney Disease Cancer
    Condition
    Other Urinary Condition Irritable Bowel / Colitis Hepatitis

    High Cholesterol Digestive Condition HIV


    Other Contagious
    Vertigo
    Condition
    Please list any Doctor Prescribed medications you presently take. (Please let us know if you require more space)

    Please list any Non-prescription vitamins, minerals, supplements or pain relievers

    Known Allergies :

    Family History of Medical Conditions?

    Have you ever been hospitalized, major accidents, illnesses, or surgeries? Please Circle One: YES / NO

    If YES, Please List Below:

    INJURY / SURGERY / ILLNESS / ACCIDENT WHEN? THERAPY RECEIVED?

    Educate Restore Movement Improve Quality Of Life


    Please CIRCLE the answer closest to how you PRESENTLY feel: (1 = POOR / 5 = EXCELLENT)

    Quality of Sleep 1 2 3 4 5 Smoker Yes No Occasional

    Energy Level 1 2 3 4 5 Alcohol Yes No Occasional


    Hours of sleep per night
    Eating Habits 1 2 3 4 5
    (Approx.)
    Stress Level 1 2 3 4 5 Meals regularly eaten per day

    Exercise Habits 1 2 3 4 5 Times you exercise per week

    Current Condition - Please describe your current condition & symptoms:

    How long did you have this condition?

    How did it start?


    What aggravates it?

    What relieves it?

    Please indicate on the diagram the nature of


    your symptoms, using the symbols indicated:

    Aching OO

    Stabbing XXX

    Shooting →→

    Burning ###

    Numbness or ≈≈
    Tingling

    Please Note: Your appointment time has been reserved for you. In courtesy of your therapist & fellow patients, we
    ask that you provide us with 24 hours notice of cancellation or a cancellation fee (full session fee) will be charged.
    Payment for all treatment is the responsibility of the patient and will be paid in advance of the treatment/consult
    session.
    I authorize the clinic, and its associated practitioners to collect my personal and medical information as
    documented above in order to contact me, and give permission for the clinic to leave messages regarding appointments
    at any of the contact numbers I have provided above. In addition, I authorize the clinic and its associated RMT’s to
    communicate with my referring MD as deemed necessary for my beneficial treatment. I also understand that my
    personal and medical information is confidential and will only be disclosed to third parties with my permission.

    Patient/Guardian Signature: Date:


    Educate Restore Movement Improve Quality Of Life

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