Confidential Patient Intake Form Page 2

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Health History: Please check  conditions you are experiencing or have experienced in the past
SKIN
HEAD / NECK
 Visual impairment
 Rashes / bruise easily
 Sinus problems
 Infectious skin conditions
 Hearing impairment
 Contagious skin conditions
 Jaw pain (TMJ pain)
 Other:
 Hearing Aid
 Allergies
 Headache / migraine
 Speech impairment
RESPIRATORY
CARDIOVASCULAR
 Stroke / cerebrovascular
 High / low blood pressure
accident
 Asthma
 Difficult breathing
 Pacemaker / internal
BP:
/
 Bronchitis
 Shortness of breath
 Bleeding disorder
defibrillator
 Chronic cough
 Smoking
 Hemophilia
 Varicose veins
 Emphysema
 Other:
 Arteriosclerosis
 Phlebitis
 Heart attack
 Poor circulation
 Angina
 Other:
MUSCLES / JOINTS Please indicate the right or left side where appropriate
 Upper back
R
L
 Tendonitis
 Leg
R
L
 Mid back
R
L
Location:
 Knee
R
L
 Lower back
R
L
 Strain
 Ankle
R
L
 Shoulders
R
L
Location:
 Foot
R
L
 Elbows
R
L
 Joint sprain / dislocation
 Weakness / loss of strength
 Arm
R
L
Location:
 Clumsiness
 Neck
R
L
 Artificial joints / pins / wires / screws
 Multiple sclerosis
 Wrist
R
L
Location:
 Osteoarthritis
 Hand
R
L
 Orthotics
 Rheumatoid arthritis
 Hip
R
L
GI CONDITIONS
INFECTIOUS CONDITIONS
 Herpes / STDs
 Tuberculosis (TB)
 Constipation
 Irritable Bowel
 Hepatitis:
 Other:
 Diarrhea
 Other:
 HIV / AIDS
OTHER CONDITIONS
PAST FRACTURES OR SURGERIES
 Yes
 No Date :
Fracture
 Allergies
 Fever
Car accident  Yes
 No Date :
 Cancer
 Insomnia
 Yes
 No Date :
Surgery
 Numbness / tingling
 Diabetes
For?
 Fainting
Where?
WOMEN
MEDICATIONS
 Pregnant? Due:
Please list all medications, natural remedies, supplements, etc.
No. of children:
 Menstrual difficulties
 Gynecological conditions:
OFFICE USE ONLY
Health History Updates / Changes
Date:
Change:
Initial:
Date:
Change:
Initial:
Change:
Date:
Initial:
Change:
Date:
Initial:
CHC Massage Intake 2 of 2
806 Gordon St. Guelph ON N1G1Y7

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