Client Intake Form - The Sharpe Physiotherapy & Massage Clinic Page 2
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Have you had
X-ray
Ultrasound
CT scan
MRI
Present Exercise program
Hobbies/ sports
Medications: nil,
pain,
steroids,
anticoagulants, nsaids- anti imflam,
other
List enclosed.
Family history
Recent or Major Surgery
Circle if you
Have Chest pain with activity
Carry nitro
Have pacemaker
Diabetes -
Type 1
type 11
Allergies
Neuropathy yes
no
Cat
dog
carry epi pen
Aspirin
Shell Fish
Other
History of falls
General
Cardiovascular
Respiratory conditions
Dizziness
High/ low pressure
Asthma
Epilepsy
Heart failure
Chronic bronchitis
Convulsions
Heart attack
Emphysema/SOB
Headaches or migraines
Stroke/Cva
Smoker
Balance problems
Sinus
Cancer -
Skin
Women
Bone/Joint
Sensitive to lotions
Menstrual problems
Osteoporosis
Rash/ eczema
Menopause
Osteoarthritis
Bruise easily
Gynecological conditions
Rheumatoid arthritis
Psoriasis
trying Pregnant or trying to
Fractures
get pregnant
Joint replacements
other
What are your goals
The information given above is accurate, current and will be confidential. Please update the
therapist whenever there is a change
Signed_________________________________________
Date_____________
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