Tlas Massage Patient History Form
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2#4-4515 Uplands Dr. Nanaimo, BC V9T 6M8
Massage Patient History Form
Name ______________________________________________ Birthdate _____________________________________
(month/day/year)
Address
____________________________________________
Family Doctor
________________________________
____________________________________________
Phone
_________________________
Postal Code
__________________________________
Referring Professional
_________________________
Phone
(home)
______________________________________
Phone
_________________________
(cell)
_______________________________________
Care Card #
_____________________________
(work)
_______________________________________
Extended Medical Insurer
___________________
□
□
Email
_____________________________________________
ICBC
Yes
No
___________________
Claim #
(
if active claim, please inform RMT as you will need to fill out a Claim Form)
Occupation
__________________________________________
How did you hear about (Registered) Massage Therapy?
__________________________________________________
How did you hear about our clinic?
____________________________________________________________________
Please indicate if you believe if any of the following apply to you?
(P= past C= current) Circle if necessary.
_ Heart Attack
_ Headaches / Migraines
_ Joint Dislocation
_ High / Low Blood Pressure
_ Dizziness / Fainting
_ Bone Fracture
_ Stroke or Aneurysm
_ Nausea
_ Arthritis
_ Pace Maker
_ Spinal Injury
_ Osteoporosis
_ other Heart condition
_ Head Injury
_ Rods / Pins / Plates / Shunts
_ Varicose Veins
_ Epilepsy / other seizures
_ Implants
______________________
_ Bruise easily
_ other Neurological conditions
_ Transplant
______________________
_ other Circulatory condition
_ Corrective Lenses / Contacts
_ Asthma
_ Diabetes
_ Chronic Sinusitis
_ Cancer
________________________
_ Kidney Disease
_ other Respiratory condition
_ Hepatitis
_ other Urinary condition
_ HIV
_ Irritable Bowel / Colitis
_ other Contagious condition
_ Digestive condition
______________________________
_ Skin condition
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:
_____________________________________________________________________________
__________________________________________________________________________________________________
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