Patient Health History Form

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Patient Health History Form
Name: ______________________________________________
Date: ___/___/___
Day Mth Yr
Address: ______________________________City: __________ Postal Code: _________
Home Phone: ____________________ Work Phone:_____________________ Ext: ______
Cell Phone: _____________________ Email Address: ____________________________
Date of Birth: ____/ ____ / ____
Occupation:__________________________________
Day
Mth
Yr
How did you hear about our clinic?_____________________________________________
Cardiovascular
Infections
Head/Neck
 high blood pressure
 hepatitis
 history of headaches
 low blood pressure
 skin conditions
 history of migraines

 TB
 vision problems
chronic congestive heart failure
 heart attack
 HIV
 vision loss
 phlebitis/varicose veins
 herpes
 ear problems
 stroke/CVA
 hearing loss
 pacemaker or similar device
Other Conditions
 heart disease
 loss of sensation, where?
Women
 pregnant, due date:
__________________
Is there a family history of any
_________________
 diabetes, onset: __________
of the above?  Yes
 No
 allergies/hypersensitivity to
 gynecological conditions,
What? _________________
what? ___________________
Respiratory
Type of reaction: ________
 chronic cough
 epilepsy
Primary Care
 shortness of breath
 cancer, where?
Physician:__________
 bronchitis
_______________________
 asthma
Address:___________
 emphysema
 arthritis
___________________
Is there a family history of any
Is there a family history of any
of the above?  Yes
 No
of the above?  Yes
 No
(e.g: digestive conditions,
Additional Medical Information
Current Medications:__________________
haemophilia, oseoporosis, mental illness)
____________________________________
___________________________________________
Condition it treats:_____________________
___________________________________________
____________________________________
Do you have any internal pins, wires, or artificial joints?
 Yes
 No
Surgery – Date ________________________
Details:_______________________________________
Nature: ______________________________
_____________________________________________
What is the reason you are seeking Massage/Osteopathy?
Injury – Date _________________________
_____________________________________________
Nature: ______________________________
_____________________________________________
Notes:
Date of Initial Health History:
Update 1:________________
Update 2:________________
Update 3:________________
Update 4:________________
Thank you for choosing Rosedale Wellness Centre

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