Health History Form 2021
Required Field
Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Gender
M
F
Identify as
Identify as
Occupation
Contact Info
Mobile Phone
Home Phone
Work Phone
Email
Source of Referral
Address
City
Country
Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State Of
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
C?te D'Ivoire
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People'S Republic Of
Korea, Republic Of
Kuwait
Kyrgyzstan
Lao People'S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Other
Medical Info
Primary Complaint
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General Health
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Current Treatment
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Past Treatment (from other practitioners)
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Medications
Injuries
Surgeries
Additional Info
Insurance Info
Insurer's Name
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Adjuster's Name
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Policy Number
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Office Address
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Unit #
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City
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Country
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Prov / State
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Postal Code / Zip
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Phone
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Fax
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Email Address
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Claims / Benefit
Conditions
TMJ (Jaw)
Difficulty Opening Jaw
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Locking
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Difficulty Chewing
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Clenching
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Grinding
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Morning Stiffness
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Ear Ringing
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Ear Stuffiness
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Ear Pressure
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Jaw Pain
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Ear Blockage
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Clicking
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Infectious
Strep
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Epstein Barr
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Lyme Disease
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Pneumonia
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Presence of any infectious condition?
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Presence of any infectious condition?
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Feet
Dry/Cracked Skin
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Plantar Fasciitis
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Hallux Valgus
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Plantar Wart
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Hammer Toe
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Previous Amputations
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Heel Fissures
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Itchy or Peeling Skin
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Mallet Toe
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Bunions
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Pes Cavus (High Arch)
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Claw Toe
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Pes Planus (Flat Feet)
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Health Questions
Congenital Heart Defect
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High blood pressure
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Schizophrenia
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Depression
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HIV/Aids
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Stroke
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Varicose veins
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Diabetes
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Low blood pressure
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Vertigo
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Asthma
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Epilepsy
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Meniere Disease
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Warts
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Blood thinner medication
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Gastrointestinal
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Migraines/Headaches
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Cancer
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Hearing Impairment
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Mood Disorder
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Cardiovascular
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Heart Attack
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Pacemaker
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Concussion
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Heart Condition
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Past Heart Surgery
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Treatment Goals
Stress Relief
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Support in Healing/Recovery
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Health Advice for Healing
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Improve Lifestyle
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Improve Symptoms
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Improve Well Being
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Pain Relief
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Rehabilitation
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Other
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Male Health
History of Back Injury
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History of STD
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Painful Urination
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Female Health
Hysterectomy
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Menopause
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PMS
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Severe Menstrual Pain
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Number of Pregnancies
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Endometriosis
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Breast Cancer
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Ovarian Cancer
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Osteoporosis
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Current Menopausal Concerns
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Currently Pregnant
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Heaviness in Pelvis
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Pelvic Organ Prolapse
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Pelvic Floor Injury
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Scar Tissue
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Pelvic Pain
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COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Changes to your medical history since initial intake?
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Willing to sanitise hands when entering and leaving clinic
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Willing to wear face mask in the clinic
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Agree to wear face mask during treatment
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Have you taken precautions to limit exposure
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Have you tested positive for COVID-19?
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Have you been tested for COVID?
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Have you had the antibody test?
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Have you been vaccinated?
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Have you been vaccinated?
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Fever Over 100.4 degrees
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Fever Over 38 degrees
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Headaches
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New Onset of Cough
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Worsening Chronic Cough
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Sore Throat
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Difficulty Swallowing
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Shortness of Breath
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Difficulty Breathing
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Persistent Pain in Chest
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Decrease or sudden loss of taste and smell
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Have you had a new onset of muscle aches and pain since the emergence of the virus?
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Unexplained Fatigue/Malaise/Muscle Aches (Myalgia)
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Fatigue
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Chills
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If a child, purple markings on fingers and toes
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Pink eye (conjunctivitis)
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Nasal or sinus congestion
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Runny nose/nasal congestion without other known cause
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Nausea
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Vomiting
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Diarrhea
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Abdominal Pain
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Sudden onset body aches
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New rash or other skin changes
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Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin?
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Regular cardio exercise
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Can you exercise to get your heart rate up without any problem?
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Can you exercise to get your respiratory rate up without any problem?
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Contact with someone with COVID
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Had close contact with a confirmed case of COVID-19 without wearing PPE
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Are you in high or moderate risk groups?
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Have you been shielding?
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Contact with someone who is awaiting COVID test results.
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Contact with someone who was in contact with COVID
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Contact with anyone with acute respiratory Illness
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Recent domestic air travel
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Recent international air travel
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Recent travel to area with high infection rates
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Recent travel outside your province within the past 14 days
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Did you travel outside of Canada in the past 14 days?
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To the best of your knowledge, within the last 14 days has any member of your household or support bubble tested positive for COVID-19 or experienced any COVID-19 symptoms?
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To the best of your knowledge, within the last 14 days have you or any other member of your household or support bubble has been exposed to anyone diagnosed with COVID-19 or experiencing COVID?
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Within the last 14 days, have you tested positive for COVID-19 or experienced any COVID-19 symptoms?
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Have you received a covid alert that you were in close contact with someone with covid, through the covid app in the last 14 days?
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Been in group where social distancing not observed
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Are you required to be self-isolating for any reason?
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Are you required to be self-isolating for any reason?
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Is anyone else in your household or that you've had close contact with experiencing any cold, flu or stomach virus like symptoms?
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Is anyone else in your household or that you've had close contact with experiencing any cold, flu or stomach virus like symptoms?
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I agree to wash/sanitize my hands before and after treatment
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No COVID Symptoms
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Do you consent to the consultation, assessment and treatment by the therapist?
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Oncology
Cancer Type
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Date of Diagnosis
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Location
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Status
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Treatment: Surgery
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Date of Surgery
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Lymph Nodes Removed
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Side Effects of Surgery
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Reconstruction Date
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Treatment: Chemotherapy
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Number of Chemo Treatments
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Side Effects of Chemo
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Treatment: Radiation
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Number of Radiation Treatments
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Area of Radiation
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Nodes Irradiated
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Side Effects of Radiation
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Other Treatments
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Medical Devices
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Nausea
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Vomiting
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Mouth Sores
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Weight Loss
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Weight Gain
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Bone Pain
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Adhesions
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Incision
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Pressure Sensitivity
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Pain
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Former Injuries
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Loss of Movement
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Abnormal Skin Sensation
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Memory Problems
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Edema
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Low Platelet
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Low White Count
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Blood Clot
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Excessively Warm/Cold
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Lymphedema
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Heart Condition
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Lung Condition
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Dry Skin
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Fragile Skin
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Radiation Skin Reaction
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Hair Loss
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Fatigue
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Systemic Infection
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Infectious Condition
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Current Tumour
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Enlarged Lymph Nodes
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Enlarged Spleen
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Enlarged Liver
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Radioactivity
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Area of Complaint
Neck
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Left Side of Upper Back
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Right Side of Upper Back
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Mid Back
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Left Side of Mid Back
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Right Side of Mid Back
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Low Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Left Thigh
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Left Calf
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Right Leg
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Right Thigh
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Right Calf
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Left Gluteal
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Right Gluteal
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Left Hip
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Right Hip
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Left Groin
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Right Groin
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Sacrum
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Tailbone (coccyx)
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Headaches
Migraines
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Cluster
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Headaches
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Rebound
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Sinus
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Chronic Daily Headache
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Tension
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Other Headaches
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Brain Disorders
Social Anxiety Disorder
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PTSD
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Acute Stress Disorder
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Anxiety
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Claustrophobia
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Panic Disorder
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Schizophrenia
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Other Psychological
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Cardiovascular
Heart Attack
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Angina
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Peripheral Vascular Disease
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Pericarditis
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Phlebitis
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Atherosclerosis
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Stroke
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Raynaud Disease
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Cold Hands
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Cardiac Arrhythmia
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Swelling
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Rheumatic Heart Disease
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Cold Feet
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Cardiovascular Accident
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Chronic Ischemic Heart Disease
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Valve Disorders
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Pacemaker
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Chronic Venous Insufficiency
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Myocardial infarction
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Chest Pain
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Heart Disease
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Congenital Heart Defect
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Varicose Veins
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High Blood Pressure
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Cardiovascular Conditions
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Fainting Spells
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Coronary Artery Disease
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Blood Clots
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Blood Pressure
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Low Blood Pressure
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Acute Coronary Syndrome
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Aneurysm
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Heart Condition
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Hyperlipidemia
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Postural Orthostatic Tachycardia Syndrome
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Lymphedema
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Congestive Heart Failure
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Other Cardiovascular
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Skin
Chemical Burn
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UV Burn
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Herpes
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Hypersensitive Reactions
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Melanoma
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Melanoma/Carcinoma
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Non-Surgical Scars
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Pigmentary Disorder
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Surgical Scars
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Plantar's Wart
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Infectious Skin Conditions
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Psoriasis
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Athlete's Foot
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Acne
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Skin Conditions
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Rash
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Eczema
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Allergic Dermatosis
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Athletes Foot
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Bruise Easily
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Skin Irritations
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Rosacea
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Hypersensitive Reaction
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Other Skin
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Immune
HIV/Aids
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Sjogren's Syndrome
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Rheumatoid Arthritis
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Anaphylaxis
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Lupus
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Allergies
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Hodgkin Lymphoma
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Infectious Mononucleosis
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Cancer
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Leukemia
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Non-Hodgkin Lymphoma
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CVID
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Other Immune
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Neurological
Loss of Sensation
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Cerebrospinal Fluid Leak
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Transient Ischemic Attacks (TIA)
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Sleeping Disorders
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Vertebral and Spinal Cord Injury
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Chiari Malformation
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Syringomyelia
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Stroke
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Huntington Disease
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Shingles
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Dural Ectasia
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Cerebral Palsy
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Tethered Cord
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Epilepsy
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Brain Disorder
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Dizziness
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Fatigue
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Parkinsons
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Twitching of Face
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Numbness
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Burning
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Chronic Pain Disorder
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Fibromyalgia
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Herniated Disc
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Tingling
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Brain Injury
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Peripheral Neuropathy
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Multiple Sclerosis
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Stabbing
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Bell's Palsy
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Cerebral Vascular Accident (Stroke)
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Post Polio Syndrome
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Cerebral-vascular Accident
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Carpal Tunnel
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Seizure Disorder
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Sciatic Pain
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Shingles / Herpes
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Other Neurological
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Musculoskeletal
Myasthenia Gravis
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Gout
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Osteoporosis
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Ankylosing Spondylitis
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Osteomalacia
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Adhesive Capsulitis
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Ehlers-Danlos Syndrome
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Temporomandibular Joint Dysfunction
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Tendonitis/Bursitis
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Bone Disease
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Sinus Problems
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Paget Disease
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Bone or Joint Disease
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Artificial Joints / Special Equipment
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Compartment Syndrome
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Psoriatic Arthritis
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Scleroderma
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Plantar Fasciitis
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Broken Bone / Fracture
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Dislocation
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Fibromyalgia
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Scoliosis
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Dupuytren's Contracture
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Joint Stiffness / Swelling
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Jaw Pain (TMJD)
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Degenerative Disk Disease
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Carpal Tunnel Syndrome
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Fracture
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Torticollis
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Strain/Sprain
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Chronic Myofascial Pain Syndrome
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Spasms / Cramps
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Arthritis
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Whiplash
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Hereditary/Congenital Deformity
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Baker's Cyst
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Amyotrophic Lateral Sclerosis (ALS)
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Chronic Fatigue Syndrome
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Joint Injury
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Recti Diastasis
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Muscular Dystrophy
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Spondylolisthesis
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Osteoarthritis
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Osgood-Schlatter Disease
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Other Musculoskeletal
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Gastrointestinal
Eating Disorder
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Gastroparesis
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Abdominal Hernia
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Esophageal Disorder
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Acid Reflux
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Fecal Impaction
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Adaptive Aids
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Intestinal Polyps
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Celiac Disease
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Hiatal Hernia
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Irritable Bowel Syndrome
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Constipation
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Intestinal Gas/Bloating
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Poor Appetite
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Diarrhea
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Stomach Disorders
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Digestive Conditions
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Stomach Disorder
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Diverticulitis
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Crohn's Disease
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Ulcerative Colitis
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Other Gastrointestinal
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Endocrine
Hyperthyroidism
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Diabetes
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Hypothyroidism
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Pituitary and Growth Disorder
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Adrenal Fatigue
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Prostate Condition
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Blood Sugar Managed?
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Temiskaming Diabetes Program
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Wound Healing Status?
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Acute Pancreatitis
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Other Endocrine
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Blood
Thrombosis/Embolism
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Anemia
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High Cholesterol
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Blood Thinner Medication
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Fainting Spells
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Bleeding Disorder
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Stroke
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HIV/AIDS
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Hypercoagulability
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Polycythemia
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Hepatitis
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Haemophilia
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HIV
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Other Blood
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Respiratory
Tuberculosis
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Chronic Cough
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Shortness of Breath
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Asthma
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Respiratory Tract Infection
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Emphysema
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COPD
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Bronchitis
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Cystic Fibrosis
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Infectious Respiratory Conditions
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Respiratory Conditions
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Sinus Problem
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Other Respiratory
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Reproductive
Premenstrual Syndrome
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Breast Disorder
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Pregnancy
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Uterine Disorder
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Ectopic Pregnancy
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Gynaecological Conditions
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Endometriosis
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Menopause
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Menstrual Cycle Disorder
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Enlarged Prostate
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Ovarian Cysts/Tumors
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Prostatitis
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Pelvic Inflammatory Disease
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Other Reproductive
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Hearing
Tinnitus
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Vertigo
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Ear Problems
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Hearing Loss
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Conductive Hearing Loss
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Meniere Disease
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Motion Sickness
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Other Hearing
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Family History
Arthritis
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Cardiovascular
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Respiratory
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Diabetes
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Cancer
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General Injury Related Questions
What is the next competition/challenge?
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Previous sports-related injuries?
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Treatment of previous injury?
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Physical Therapy
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Chiropractic
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OTC medications
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Pain medications or steroids
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Surgery (type/year)
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Complications from that injury?
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Miscellaneous
ADHD
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Mental Health Issues
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Autism
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Insomnia
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Hearing Impaired
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Loss of Balance
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Music Preference
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Upper Respiratory Infection
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Weakened Immune Function
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Other Medical Conditions
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Other Diagnosed Diseases
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Prenatal (check boxes to enter details below)
Name of midwife/OBGYN
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Other prenatal concerns
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Any pregnancy complications or health issues?
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Due Date
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Trimester
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Weeks Pregnant
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Number of previous pregnancies/births?
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Anemia
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Leaking Amniotic Fluid
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Bladder Infection
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Blood Clot (Phlebitis)
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Abdominal Cramping
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Diabetes
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Edema/Swelling
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Leg Cramps
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Miscarriage
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Nausea
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Problems with Placenta
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Preterm Labour
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Pre-eclampsia (toxemia)
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Sciatica
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Separation of Rectus Muscle (diastasis recti)
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Separation of Symphysis Pubis
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Twins or More
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Visual Disturbances
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Previous C-Section
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Heart Attack
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Stroke
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Carpal Tunnel Syndrome
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Allergy to Nut Oils
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Hypoglycemia
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High Risk Pregnancy
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Birth Location
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Doula
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Placental Location
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Baby's Sex
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Sacral Injury
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Tailbone Injury
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Postpartum (check boxes to enter details below)
Name of midwife/OBGYN
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Any birth/postpartum complications or health issues?
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Number of weeks postpartum
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Any current limitations on your activity?
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Other postpartum concerns
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Birth Location
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Vaginal or cesarean birth?
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Currently lactating or nursing?
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Date you gave birth
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Diastasis recti
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Have you seen your midwife/OBGYN since giving birth?
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Massage Goals
Improve Fitness
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Improve Symptoms
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Increase Well-Being
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Injury Rehabilitation
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Pain Relief
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Address Health Issues
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Positive Reinforcement
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Alternative Therapy
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Strength Training
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Balance
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Flexibility
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Stress Relief
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Date of Last Massage
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Massage Frequency
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Light Pressure Preferred
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Medium Pressure Preferred
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Other
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Deep Pressure Preferred
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Accident Info
Date of Injury
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Which State?
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MVA Claim
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Workers Comp Claim
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Crime Victim Comp.
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Which best describes what you are experiencing
Pain
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Mild
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Getting Worse
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Ache
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Moderate
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Staying the Same
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Tension
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Disabling
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Getting Better
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Discomfort
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Constant
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Imbalance
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Intermittent
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Increases with Activity
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Decreases with Activity
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No Change
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Other
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Current Complaint
Pain Severity: 1-10
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Date of Injury?
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Prescription pain meds Did it help?
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Steroids (oral) Did it help?
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Steroids (injection) Did it help?
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Heat Did it help?
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Cold Did it help?
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Immobilization Did it help?
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Other creams, gels or unguents
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Other therapies
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Physical Activities You Participate In
Soccer
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Hockey
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Crossfit
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Softball
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Football
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Swimming
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Golf
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Tennis
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Lacrosse
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Triathlon
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Marathon
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Waterpolo
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Hockey
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Pilates
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Weight Lifting
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Baseball
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Rugby
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Running
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Yoga
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Basketball
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Other Activities
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Number of Times of Week You Practice
Once a week
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2-4 times a week
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More than 4 times a week
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Less than a couple of times a month
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Allergy
Latex
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Mastocytosis
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MCAD
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Medical
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Miscellaneous
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Coconut Oil
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Sensitive to scents/essential oils
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Environmental
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Food
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Other Allergies
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Emotion / Mood
Grief
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Sadness
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Anxiety
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Mental Abuse History
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Stress Response and Coping Strategies
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Confusion
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Negative Self-Talk
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Depression
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Despair
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Other Emotions
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Overall mood and energy level
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Physical Abuse History
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PTSD
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Fear
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Rate the stress in your life (1-10)
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Anger
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