For Your Health - Health History

Personal Info

First Name *

Last Name *

Date of Birth *

Gender *

Identify as

Occupation

Contact Info

Mobile Phone

Home Phone

Work Phone

Address *

City *

Country

Province / State *

Postal / Zip Code

Doctor

Doctor's Name

Doctor's Phone

Doctor's Address

Medical Info

Primary Complaint

General Health

Source of Referral

Current Treatment

Past Treatment (from other practitioners)

Medications

Injuries

Surgeries

Additional Info

Conditions

Emotion / Memory

Alzheimer Disease

Comments

Alzheimer Disease

Treatment Goals

Improve Symptoms

Improve Well Being

Pain Relief

Rehabilitation

Stress Relief

Support in Healing/Recovery

Other

Comments

Improve Symptoms

Improve Well Being

Pain Relief

Rehabilitation

Stress Relief

Support in Healing/Recovery

Other

Health Questions

Asthma

Blood thinner medication

Cancer

Cardiovascular

Concussion

Congenital Heart Defect

Depression

Diabetes

Epilepsy

Gastrointestinal

Hearing Impairment

Heart Attack

Heart Condition

High blood pressure

HIV/Aids

Low blood pressure

Meniere Disease

Migraines/Headaches

Mood Disorder

Pacemaker

Past Heart Surgery

Schizophrenia

Stroke

Varicose veins

Vertigo

Warts

Comments

Asthma

Blood thinner medication

Cancer

Cardiovascular

Concussion

Congenital Heart Defect

Depression

Diabetes

Epilepsy

Gastrointestinal

Hearing Impairment

Heart Attack

Heart Condition

High blood pressure

HIV/Aids

Low blood pressure

Meniere Disease

Migraines/Headaches

Mood Disorder

Pacemaker

Past Heart Surgery

Schizophrenia

Stroke

Varicose veins

Vertigo

Warts

COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)

Have you been tested for COVID?

Fever Over 38 degrees

Headaches

New Onset of Cough

Worsening Chronic Cough

Sore Throat

Difficulty Swallowing

Shortness of Breath

Difficulty Breathing

Persistent Pain in Chest

Decrease or sudden loss of taste and smell

Have you had a new onset of muscle aches and pain since the emergence of the virus?

Unexplained Fatigue/Malaise/Muscle Aches (Myalgia)

Fatigue

Chills

Pink eye (conjunctivitis)

Nasal or sinus congestion

Runny nose/nasal congestion without other known cause

Nausea

Vomiting

Diarrhea

Abdominal Pain

Sudden onset body aches

Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin?

Contact with someone with COVID

Had close contact with a confirmed case of COVID-19 without wearing PPE

Contact with anyone with acute respiratory Illness

Recent domestic air travel

Recent international air travel

Recent travel outside your province within the past 14 days

Did you travel outside of Canada in the past 14 days?

Been in group where social distancing not observed

Have you taken precautions to limit exposure

Are you considered high risk?

If over 70, unexplained or increase number of falls?

If over 70, acute functional decline?

If over 70, worsening of chronic conditions?

If over 70, symptoms of delirium?

Willing to wash hands before entering clinic

Willing to wash hands before leaving clinic

Willing to wear face mask in the clinic

Agree to wear face mask during treatment

Comments

Have you been tested for COVID?

Fever Over 38 degrees

Headaches

New Onset of Cough

Worsening Chronic Cough

Sore Throat

Difficulty Swallowing

Shortness of Breath

Difficulty Breathing

Persistent Pain in Chest

Decrease or sudden loss of taste and smell

Have you had a new onset of muscle aches and pain since the emergence of the virus?

Unexplained Fatigue/Malaise/Muscle Aches (Myalgia)

Fatigue

Chills

Pink eye (conjunctivitis)

Nasal or sinus congestion

Runny nose/nasal congestion without other known cause

Nausea

Vomiting

Diarrhea

Abdominal Pain

Sudden onset body aches

Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin?

Contact with someone with COVID

Had close contact with a confirmed case of COVID-19 without wearing PPE

Contact with anyone with acute respiratory Illness

Recent domestic air travel

Recent international air travel

Recent travel outside your province within the past 14 days

Did you travel outside of Canada in the past 14 days?

Been in group where social distancing not observed

Have you taken precautions to limit exposure

Are you considered high risk?

If over 70, unexplained or increase number of falls?

If over 70, acute functional decline?

If over 70, worsening of chronic conditions?

If over 70, symptoms of delirium?

Willing to wash hands before entering clinic

Willing to wash hands before leaving clinic

Willing to wear face mask in the clinic

Agree to wear face mask during treatment

Prenatal (check boxes to enter details below)

Due Date

Comments

Due Date

Massage Goals

Address Health Issues

Balance

Flexibility

Increase Well-Being

Injury Rehabilitation

Stress Relief

Date of Last Massage

Massage Frequency

Light Pressure Preferred

Medium Pressure Preferred

Other

Deep Pressure Preferred

Comments

Address Health Issues

Balance

Flexibility

Increase Well-Being

Injury Rehabilitation

Stress Relief

Date of Last Massage

Massage Frequency

Light Pressure Preferred

Medium Pressure Preferred

Other

Deep Pressure Preferred

Current Complaint

Pain Severity: 1-10

Date of Injury?

Prescription pain meds Did it help?

Steroids (oral) Did it help?

Steroids (injection) Did it help?

Heat Did it help?

Cold Did it help?

Immobilization Did it help?

Other creams, gels or unguents

Other therapies

Comments

Pain Severity: 1-10

Date of Injury?

Prescription pain meds Did it help?

Steroids (oral) Did it help?

Steroids (injection) Did it help?

Heat Did it help?

Cold Did it help?

Immobilization Did it help?

Other creams, gels or unguents

Other therapies

Allergy

Miscellaneous

Comments

Miscellaneous

Musculoskeletal

Adhesive Capsulitis

Amyotrophic Lateral Sclerosis (ALS)

Ankylosing Spondylitis

Arthritis

Artificial Joints / Special Equipment

Baker's Cyst

Bone Disease

Bone or Joint Disease

Broken Bone / Fracture

Carpal Tunnel Syndrome

Chronic Fatigue Syndrome

Chronic Myofascial Pain Syndrome

Compartment Syndrome

Degenerative Disk Disease

Dislocation

Dupuytren's Contracture

Ehlers-Danlos Syndrome

Fibromyalgia

Fracture

Gout

Hereditary/Congenital Deformity

Jaw Pain (TMJD)

Joint Injury

Joint Stiffness / Swelling

Muscular Dystrophy

Myasthenia Gravis

Osgood-Schlatter Disease

Osteoarthritis

Osteomalacia

Osteoporosis

Paget Disease

Plantar Fasciitis

Psoriatic Arthritis

Recti Diastasis

Scleroderma

Scoliosis

Sinus Problems

Spasms / Cramps

Spondylolisthesis

Strain/Sprain

Temporomandibular Joint Dysfunction

Tendonitis/Bursitis

Torticollis

Whiplash

Other Musculoskeletal

Comments

Adhesive Capsulitis

Amyotrophic Lateral Sclerosis (ALS)

Ankylosing Spondylitis

Arthritis

Artificial Joints / Special Equipment

Baker's Cyst

Bone Disease

Bone or Joint Disease

Broken Bone / Fracture

Carpal Tunnel Syndrome

Chronic Fatigue Syndrome

Chronic Myofascial Pain Syndrome

Compartment Syndrome

Degenerative Disk Disease

Dislocation

Dupuytren's Contracture

Ehlers-Danlos Syndrome

Fibromyalgia

Fracture

Gout

Hereditary/Congenital Deformity

Jaw Pain (TMJD)

Joint Injury

Joint Stiffness / Swelling

Muscular Dystrophy

Myasthenia Gravis

Osgood-Schlatter Disease

Osteoarthritis

Osteomalacia

Osteoporosis

Paget Disease

Plantar Fasciitis

Psoriatic Arthritis

Recti Diastasis

Scleroderma

Scoliosis

Sinus Problems

Spasms / Cramps

Spondylolisthesis

Strain/Sprain

Temporomandibular Joint Dysfunction

Tendonitis/Bursitis

Torticollis

Whiplash

Other Musculoskeletal

Respiratory

Asthma

Chronic Cough

COPD

Emphysema

Respiratory Conditions

Shortness of Breath

Other Respiratory

Comments

Asthma

Chronic Cough

COPD

Emphysema

Respiratory Conditions

Shortness of Breath

Other Respiratory

Miscellaneous

Surgical Pins or Wire

Comments

Surgical Pins or Wire

Accept & Send

I accept the Consent for Assessment and Treatment of Sensitive Areas