midhurstphysio_OldStone

DATE

Date

NAME

Address

ADDRESS

Street Address Line 2

CITY

POSTAL CODE

DATE OF BIRTH

Date

PRIMARY PHONE no.

Check:

CellHome

Occupation

Preferred Language

Preferred Pronouns

Accessibility Needs

Are you OK to climb stairs at this time?

YESNO

Have you had massage therapy before?

YESNO

Have you received treatment from another health care professional in the past year?

YESNO

FAMILY PHYSICIAN

Initial

CITY

Emergency Contact

Phone Number

Please enter a valid phone number.

INJURY/AREA TO BE TREATED

0/80

Do you have extended healthcare coverage?

YesNo

If I qualify for online billing, I understand that I am responsible to keep track of treatment costs and how muchcoverage is available in my plan. I understand that I am responsible for any treatment costs not covered by my plan. (Initial)

I WAS REFERRED TO Midhurst Wellness Centre BY:

Do you have any allergies?

YesNo

If yes, to what?

Please list any recent/current injuries, and dates of occurrence:

0/80

Were these injuries sustained at work or as result of a motor vehicle collision?

YesNo

Please list all surgeries and dates:

0/80

Are you experiencing any of the following: chronic pain, fatigue, tension, swelling, numbness/tingling,and/or inflammation?

YesNo

If yes, please describe:

List any health issues you have related to the following categories that may impact your massage therapy care:

	Yes	Describe
Muscle, joint, or bone issue (eg.: arthritis, muscle strain, ligament sprain…):
Heart or circulation concerns (eg.: high blood pressure, pace maker…):
Lung or breathing issues (eg.: asthma, COPD…):
Neurological symptoms or conditions (eg.: dizziness, numbness, epilepsy/seizures. Stroke, MS…):
Skin conditions that may impact your treatment (eg.: bruise easily, eczema, rashes …):
Gynaecological concerns (eg.: pregnancy, menopause, menstrual concerns…):
Other conditions that may impact your massage therapy care (hearing loss, diabetes…):

Are you taking any medications that may affect your sensitivity, healing, or ability to receive massage(eg.: blood thinners, pain medication, corticosteroids, recreational drugs)?

YesNo

If yes, please provide more info:

Cancer Treatment History: Have you been diagnosed with cancer, received, or are currently receiving cancer treatment (chemotherapy, radiation, surgery)?

YesNo

If yes, please describe any symptoms this may be causing you, as massage therapy can help to address many of the symptoms relates to cancer treatment.

Physical Symptoms related to mental health (eg.: stress, anxiety, depression): Mental health concerns cancontribute to physical symptoms, and many of these physical symptoms can be addressed by massagetherapy. Are you experiencing any physical symptoms such as fatigue, tension, muscle pain, or sleepdisturbances that may relate to mental health?

YesNo

If yes, please describe:

I have read the above information and have stated previous & current medical conditions that that are relevant to my massage therapy treatment. I will update my RMT regarding any updates in my condition as soon as possible.

In order to provide treatment, this clinic must collect personal health information. I understand that all information that I provide will be kept confidential unless allowed or required by law. I understand that I will be asked for written authorization before this information can be released. I consent to treatment for the above mentioned conditions, and to the communication between the treating professionals at this clinic and/or Physicians or other Health Care Professionals.

I understand there is a 24-hour cancellation policy and I agree to pay the missed appointment fee (100% of the appointment fee) or the late cancellation fee (50% of the appointment fee). I understand that I am responsible to pay for the time reserved with the Registered Massage Therapist; regardless of the time I arrive and am ready for my appointment. I understand that this time will include intake, assessment, treatment, and self-care recommendations. I understand that payment in full is due on the day of treatment.

Signature

Date

Permission to verify information on issued receipt with patient’s insurer?

YesNo

OLD STONE MASSAGE THERAPY: MIDHURST WELLNESS CENTRE: CONFIDENTIAL MEDICAL INFORMATION

General Health Information

Optional Health Disclosures

Please ensure you read the following information in its entirety.