Confidential Client History Form

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone (home)

Phone (cell/pager)

Phone (work)

Email*

Occupation

Birthdate*

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.

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

Location of last Massage Therapy

Date of last Chiropractic

Location of last Chiropractic

Date of last Physiotherapy

Location of last Physiotherapy

Date of last Naturopathy

Location of last Naturopathy

Date of last Acupuncture

Location of last Acupuncture

Type of Other treatment/therapy

Date of last Other therapy / treatment

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

Energy Level

Eating Habits

Stress Level

1 is no stress, 5 is very stressed

Exercise Habits

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.

Referral and claim info

Conditions and Treatment

Please choose the number closest to how you PRESENTLY feel:

Current Condition

604-538-7166

buenavistamassage@gmail.com