Confidential Patient Case History
Please complete the form below. 
Print a copy and present to the therapist prior to treatment.
or
Download client form (Word file)


REGISTERED MASSAGE THERAPY CLINIC
For your information:
An accurate health history is important to ensure that it is safe for you to receive a massage treatment. If your health status changes in the future, please let me know. All information gathered for this treatment is confidential except as required by law or except to facilitate assessment or treatment. You will be asked to provide written authorization for release of any information.
CLIENT CONTACT INFORMATION
Name:
Date of Birth:
Address:
City / Town:
Province:
Postal Code:
E-mail:
Occupation:

Phone:
 (H) (W) (cell / pager) (Fax)
Who referred you?
How did you hear about us?
business card friend kangas sauna newspaper website other
Health History (Please indicate conditions you are experiencing, or have experienced.)

Circle those you currently have.
Respiratory :
 chronic cough shortness of breath bronchitis asthma
emphysema , other
Cardiovascular:
 high blood pressure low blood pressure phlebitis
CCHF (chronic congestive heart failure)
heart attack, How long ago:
heart disease, Type:
stroke / CVA (cerebrovascular accident)
pacemaker or similar devise other
Other conditions:
 loss of sensation diabetes: onset
allergies (ie.anaphylaxis or skin irritation) epilepsy
cancer: type arthritis: type
Head / Neck:
 vision problems vision loss ear problems hearing loss
headaches (tension, migraine) glasses / contact lenses
other
Soft tissue / joint discomfort and its nature:
 neck
mid back
shoulders
legs
feet 		low back
upper back
arms / hands
knees
other
Infections:
 hepatitis skin conditions TB (Tuberculosis)
HIV (human immunodeficiency virus) other
Women:
 pregnant: due
Skin:
 skin conditions: type

Others:
chill easily drug withdrawal chronic problems
flu / cold nerve pain / inflammation contagious disorder
hemophilia nervousness spinal disorder
current injury hypoglycemia osteoporosis
swelling / edema dentures hyperglycemia
pins / plates / screws syncope (fainting) depression
immunosupression previous hospitalization varicose veins
disorder of an organ injection (recent) previous injuries
none of the above apply MVA (motor vehicle accident) When:
Family history of:
arthritis cancer diabetes heart disease spinal problems stroke other

Current Medications:
Primary Care Physician:
Condition it treats:
Telephone:
Surgery:
Date:
Address:
Present involvement in other healthcare: Yes No
Nature:
Type of Provider: chiro physio other
Injury: No Yes, please specify Date: Nature:

Other Medical conditions (eg. Digestive conditions, gynaecological conditions, etc.):

Of Special Note: (presence of internal pins, wires, artificial joints, special equipment):


Check if you use:
dietary supplements tobacco alcohol caffeine unprescribed drugs
REASON FOR YOUR VISIT / WHAT'S BOTHERING YOU

Main complaint: (Onset- How-Progression-Location)
Type of pain:
aches gripping dull burning numbness sharp shooting sore
stabbing throbbing tingling weak other
Grade the pain:
(Low) 1 2 3 4 5 6 7 8 9 10 (High)
Pain Worse at What Time: AM PM
Frequency of pain:
constant daily weekly monthly acute chronic interferes with sleep
Does the pain radiate: No Yes, Where:
What relieves your condition? (Activity, food, heat, ice, movement, position, smell)


What aggravates it? (Activity, food, heat, ice, movement, position, smell)
Have you tried anything for your condition? No Yes, What:
Have you had this condition before? No Yes Other Complaints
Have you had massage therapy before? No Yes, Where
What do you hope massage therapy can do for you?
Are you presently under a lot of stress? No
Yes, (Low ) 1 2 3 4 5 6 7 8 9 10 (High)

PLEASE NOTE THAT 24 HOURS NOTICE IS REQUIRED FOR THE CANCELLATION OF AN APPOINTMENT. FULL PAYMENT IS REQUIRED FOR A MISSED APPOINTMENT. IF YOU ARE SICK, OR ARE OTHERWISE UNABLE TO ATTEND FOR YOUR ALOTTED TIME, PLEASE CALL TO MAKE OTHER ARRANGEMENTS. APPOINTMENTS ARE TO BE BOOKED IN ADVANCE. I have read and thoroughly understand all of the above form. The information given is correct and complete to my knowledge. I shall notify the therapist upon any changes or updates of my health or medications so my file information remains current. As stated in the "Consent to Treatment" Act, I have the right to consent to all or part of the session, or to withdraw consent at any time. I have the right to know specifically what I am consenting to. If the description of the session beforehand is incomplete, I have the right to ask questions at any time and to have them adequately answered. I will communicate information (such as pain/discomfort levels) throughout the session to ensure my own safety and the effectiveness of the session. I consent to treatments.


 

Doris Tamminen-Wong, RMT (807) 476-6050. 379 Oliver Rd, Thunder Bay, ONT P7B 2G1

E-Mail: dwong@massagehierontaa.com

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