604-538-7166
Home
About
About Buena Vista Massage
Testimonials
Community Events
Conditions Treated
Conditions Treated
Rates & Cancellation Policy
Blog
Resources
Client History Form
Contact Us
Confidential Client History Form
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone (home)
Phone (cell/pager)
Phone (work)
Email
*
Occupation
Birthdate
*
Date Format: MM slash DD slash YYYY
Referral and claim info
Family Doctor
Family Doctor's Phone
Referring Professional
Referring Professional's Phone
Personal Health # (PHN)
Extended Medical Insurer
ICBC or WCB?
Yes
No
Claim#
(if active claim, please inform RMT as you will need to fill out the related claim form)
How did you hear about (Registered) Massage Therapy?
How did you hear about our clinic?
Conditions and Treatment
Please indicate if you believe if any of the following apply to you?
You may provide additional information in the box following this question.
Heart Attack
High / Low Blood Pressure
Stroke or Aneurysm
Pace Maker
other Heart condition
Varicose Veins
Bruise easily
other Circulatory condition
Diabetes
Kidney Disease
other Urinary condition
Headaches / Migraines
Dizziness / Fainting
Nausea
Spinal Injury
Head Injury
Epilepsy / other seizures
other Neurological condition
Asthma
Chronic Sinusitis
other Respiratory condition
Irritable Bowel / Colitis
Digestive condition
Skin condition
Joint Dislocation
Bone Fracture
Arthritis
Osteoporosis
Rods / Pins / Plates / Shunts
Implants (please indicate type below)
Transplant (please indicate type below)
Corrective Lenses/Contacts
Cancer (please indicate type below)
Hepatitis
HIV
other Contagious condition (please describe)
Additional notes
(optional)
Please list any Medications you presently take:
Known Allergies
(including medications, foods, seasonal, oils and lotions, etc.)
Do you have any family history of medical conditions?
Yes
No
Please list:
Have you ever been hospitalized, had any major accidents, illnesses, or surgeries?
Yes
No
Please comment:
Other therapy / treatment:
(past or present, does not have to be related to this visit)
Massage Therapy
Chiropractor
Physiotherapy
Naturopath
Acupuncture
Other
Date of last Massage Therapy
Date Format: MM slash DD slash YYYY
Location of last Massage Therapy
Date of last Chiropractic
Date Format: MM slash DD slash YYYY
Location of last Chiropractic
Date of last Physiotherapy
Date Format: MM slash DD slash YYYY
Location of last Physiotherapy
Date of last Naturopathy
Date Format: MM slash DD slash YYYY
Location of last Naturopathy
Date of last Acupuncture
Date Format: MM slash DD slash YYYY
Location of last Acupuncture
Type of Other treatment/therapy
Date of last Other therapy / treatment
Date Format: MM slash DD slash YYYY
Location of last Other therapy / treatment
List any Activities, Sports, Hobbies
(ie. Jogging, Hockey, Crafts, Computer, etc)
List any NON-prescription vitamins, minerals or other supplements you are taking:
Please choose the number closest to how you PRESENTLY feel:
1 being poor and 5 being excellent
Quality of Sleep
1
2
3
4
5
Energy Level
1
2
3
4
5
Eating Habits
1
2
3
4
5
Stress Level
1 is no stress, 5 is very stressed
1
2
3
4
5
Exercise Habits
1
2
3
4
5
Hours of sleep per night (approx.)
Number of meals you regularly eat per day
Number of times you exercise per week
Do you smoke?
Yes
No
Occasionally
Do you drink alcohol?
Yes
No
Occasionally
Current Condition
Please describe your current condition & symptoms:
(also indicate the location of sensations such as aching, stabbing, shooting, burning, numbness, or tingling)
How long have you had this condition?
How did it start?
What aggravates it?
What relieves it?
Consent
*
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 will be charged. During the coronavirus pandemic, the fee will be waived if the cancellation is due to signs and symptoms directly related to COVID-19.
Payment for all treatment, whether private or insured, is ultimately the responsibility of the patient.
I authorize the clinic and its associated RMTs 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 RMTs 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.
I agree.
Comments
This field is for validation purposes and should be left unchanged.
If you are unable to see the online form, please
Download the New Patient Form
.