Tuxedo_MT_Patient_Information

Last Name

First Name

Initial

Date of Birth

Date

Identifying Gender

Address (#, Street Name)

City/Prov

Postal Code

Cell Phone

Please enter a valid phone number.

Home Phone

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

Ext

Email Address

example@example.com

Preferred method of contact:

TextPhoneEmail

Who referred you?

Occupation

Employer

Emergency Contact

Relationship

Phone Number

Please enter a valid phone number.

Consent for Assessment and Treatment

Before treatment begins, your therapist will develop and propose a personalized treatment plan based on your health history and initial assessment. The assessment may consist of various orthopedic tests depending on your condition. You will be informed of what areas the proposed treatment will include, what clothing it is suggested that you remove (if any) and all anticipated outcomes of the treatment. You may alter or withdraw your consent at any time during the massage treatment.

A sheet and blanket will cover you at all times. With your consent, an area will be undraped, worked on and re-draped before continuing to the next area. At no time should you feel exposed. You may experience temporary soreness 24-48 hours after a massage therapy treatment.

I agree

Cancellation/No Show Policy

Your appointment time is reserved for you. We require 24 hours' notice for any cancellations. Patients who provide less than 24 hours' notice will be charged a $35 cancellation fee. Patients who do not cancel and do not show up for their appointment will be charged a $45 no show fee.

I am aware of the Cancellation/No Show Policy

Consent for Communication/Release of Information

I authorize the clinic and its associated health professionals to communicate with my doctor, massage therapist, dentist, chiropractor, naturopathic doctor or others deemed as 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 agreeI do not want my information shared with my other health care practitioners.

Email Communication

Effective July 1, 2014, Canada's new anti-spam legislation requires us to secure your consent so that we can communicate with you electronically.

We would like your permission to send you the following:

Email reminders of upcoming appointmentsInstructions and videos regarding prescribed exercises and updates regarding the same.Notifications regarding upcoming classes/workshops/services.

Name of Patient

Name of Guardian (if applicable)

Signature

Date

Blue Cross Manitoba Insurance:

Please complete this section if you have a Blue Cross Insurance for Massage Therapy:

ID #

Policy #

Name of subscriber (if not yourself)

Medical Information:

Family Physician

Address

Phone Number

Please enter a valid phone number.

Please list any major injuries or surgeries

Please list current medications

Have you taken any Advil or Tylenol in the last 48 hours?

YesNo

Presence of

PacemakerArtificial JointsInternal Wires/Pins

Primary Pain/Injury Area

Secondary Pain/Injury Area

Health Conditions. Muscle, Skeletal and Nervous Systems

	Indicate with a C if current or an P if past.
tension or migraine headaches
whiplash/motor vehicle accident
neck or shoulder pain or stiffness
back or hip pain or stiffness
upper extremity weakness or tingling
lower extremity weakness or tingling
head trauma or concussion
loss of coordination or dizziness
sleep or personality changes
light-headedness/fatigue
epilepsy/ seizures
TMJ or tooth, jaw or ear pain
vision or hearing loss or difficulty
degenerating discs
osteo or rheumatoid arthritis
osteoporosis or bone disease
spasm, strain or sprain
tendonitis, fibrositis or bursitis
fractures/pins, wire, plates
carpal tunnel syndrome
loss of sensation

Heart and Circulatory Systems

	Indicate with a C if current or an P if past.
blood pressure: high or low
chronic congestive heart failure
heart disease/attack or stroke (CVA)
chest pain or angina
pacemaker or similar device
varicose veins or phlebitis
cold hands & feet or swelling
diabetes
poor healing/bruise easily

Breathing System

	Indicate with a C if current or an P if past.
asthma
bronchitis or emphysema
hortness of breath
frequent colds or sinus infections
chronic cough/smoking

Skin and Immune System

	Indicate with a C if current or an P if past.
open sores, cuts or warts
contagious skin disease
tuberculosis or hepatitis
HIV
cancer
allergies (food, environmental)

Digestive System

	Indicate with a C if current or an P if past.
nausea or vomiting
constipation
rapid weight loss
appetite changes
diarrhea
bad taste in mouth
irritable bowel
ulcers
gallbladder problems

Genitourinary System

	Indicate with a C if current or an P if past.
painful urination
unusual colour/odour
gynecological concerns
pregnant currently
caesarean section

Patient Information