Health History Form

Touch Works London
RMT
...with mindfulness and integry

637 Wellington St., London On N6A 3R8

HEALTH HISTORY FORM

The information request below will assist us in treating you safely. Feel free to ask any questions about the information being requested. All information will be kept confidential unless allowed or required by law. Your written permission will be required to release any information.

How did you find out about our clinic:

Friend/RelativeHealth Care PractitionerGoogleYellow PagesOther

Have you received a massage before?

YesNo

Please indicate conditions you are experiencing or have experienced:

Cardiovascular

High Bld PressureLow Bld PressureChronic Congestive Heart FailureHeart AttackPhlebitis/Varicose VeinsStroke/CVAPacemaker or Similar DeviceHeart Disease

Respiratory

Chronic CoughShortness of BreathBronchitisCOPDAsthmaEmphysemaPneumonia

Infections

ShinglesPlantar WartsHepatitisSkin ConditionsTBHerpes

Head/Neck

History of HeadachesHistory of MigrainesVision ProblemsVision LossEar ProblemsHearing LossWhiplashConcussion

Women

Pregnant

, due date:  

Gynecological Issues

Muscular/bones/joints

SprainStrainsBroken Bone/sShoulder SeparationHerniated DiscJoint Replacement, where, when

Other Conditions

Loss of SensationArthritis OA or RADiabetesAllergiesEpilepsyCancerOsteoporosis

Do you have any other medical conditions e.g., digestive conditions, hemophilia, HIV/AIDS, mental illness?

YesNo

Have you ever been in an accident?

Motor VehicleOther
When?


Over the counter drugs you are presently taking e.g. Advil, Tylenol, Aspirin
Taken Today?
YesNo

Are you under any specialist's care?
NoYes
Name:
Present Health Care:
ChiropracticChinese MedicineNaturopathy/HomeopathyOsteopathPhysiotherapist

If you have a specific condition/injury that you are experiencing please complete the following:

Level of discomfort:

mild 12345678910 severe

Please mark all that apply

ConstantIntermittentCertain MovementDull PainAchySharp PainBurningTinglingSwelling

CONSENT FOR MASSAGE THERAPY TREATMENT

I have completed an accurate health history and agree to make known to the therapist should there be any changes to my health including medication changes. I understand I can ask any questions and that if at any time I feel uncomfortable I can ask the therapist to stop or alter the massage. Should I experience any unusual sensations during the massage I will let the therapist know.

Signature     Date:


Notes:

Health History Update: