Confidental Patient Information Form

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CONFIDENTAL PATIENT INFORMATION
Date:
__________________
Name
Occupation
:
___________________________________
:___________________________________
Address:_____________________________ City:____________________ Postal Code:________
Home Phone: ______________ Business Phone: ________________
Cell Phone:______________
Age:____ Date of Birth: dd
____mm____yr____
Email Address:___________________________
Are you currently seeing a Health Professional? __Yes __No (example: Chiro., Physio., Nat.Path?)
If yes, please explain:_____________________________________________________________
Referred by:_____________________________________________
Is this your first massage? __Yes __No When was your last massage?:____________________
Major Complaint:_________________________________________________________________
What are your treatment goals?_____________________________________________________
How do you like your massage? __ Light __Medium __Deep __Not sure
HEALTH HISTORY: (please check any condition that applies to you)
General:
Respiratory:
Cardiovascular:
Muscles and Joints
:
 Headaches
 Shortness of
 High/Low
 Stiffness
 Type:
breath
Blood pressure
 Swelling
________
 Smoker
 Poor circulation
 Limitation of
 Fibromyalgia
 Asthma
 Heart disease
movement
 Multiple
 Chronic
 Phlebitis/
 Back pain
Sclerosis
bronchitis
Thrombosis
 Shoulder pain
 Allergies
 Other
 Other
 Neck pain
Skin:
Digestive:
 Chronic pain
 Pain in limbs
 Chronic fatigue
 Sensitive
 Diabetes
 Pins and needles
 Dizziness
skin/rashes
 Digestive
in limbs
 Other
 Allergies
disorder
 Rheumatoid
Women:
 Bruise easily
 Other
arthritis
 Pregnant
 Varicose veins
Other:
 Osteoarthritis
 Stage:
 Other
 Cancer/tumors
 Whiplash
________
 Depression
 Other
 Other
If you checked “Other”, please explain:______________________________________________________________
Any other complications, aches or pains?:____________________________________________________________
Surgery/Injury:
Current Medications and Conditions treated:
Type:______________________________
__________________________________________________
Date: ______________________________
__________________________________________________
Current symptoms:___________________
__________________________________________________
Pins, wires, or plates?:________________
__________________________________________________
I understand that the information that I give on this form will be confidential and will be used for no other purpose
than the therapist’s clinical records.
I understand that I must give at least 24 hours notice for cancellations of an appointment; otherwise a treatment
fee will be charged.
Date:_______________________________
Signature:________________________________________________

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