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Province / State
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Doctor
Doctor's Name
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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
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Additional Info
Conditions
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Rehabilitation
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Stress Relief
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Support in Healing/Recovery
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Improve Symptoms
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Improve Well Being
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Other
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Health Questions
Meniere Disease
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Vertigo
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Asthma
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Epilepsy
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Gastrointestinal
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Migraines/Headaches
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Warts
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Blood thinner medication
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Hearing Impairment
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Mood Disorder
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Cancer
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Heart Attack
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Pacemaker
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Cardiovascular
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Heart Condition
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Past Heart Surgery
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Concussion
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High blood pressure
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Schizophrenia
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Congenital Heart Defect
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HIV/Aids
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Stroke
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Depression
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Low blood pressure
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Varicose veins
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Diabetes
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Emotion / Memory
Alzheimer Disease
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COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Willing to wash hands before entering clinic
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Willing to wash hands before 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 been tested for COVID?
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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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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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Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin?
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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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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 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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Been in group where social distancing not observed
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Are you considered high risk?
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If over 70, unexplained or increase number of falls?
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If over 70, acute functional decline?
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If over 70, worsening of chronic conditions?
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If over 70, symptoms of delirium?
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Musculoskeletal
Bone or Joint Disease
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Spondylolisthesis
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Dupuytren's Contracture
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Joint Injury
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Paget Disease
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Plantar Fasciitis
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Broken Bone / Fracture
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Strain/Sprain
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Ehlers-Danlos Syndrome
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Joint Stiffness / Swelling
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Adhesive Capsulitis
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Psoriatic Arthritis
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Carpal Tunnel Syndrome
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Temporomandibular Joint Dysfunction
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Fibromyalgia
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Muscular Dystrophy
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Amyotrophic Lateral Sclerosis (ALS)
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Recti Diastasis
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Chronic Fatigue Syndrome
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Tendonitis/Bursitis
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Fracture
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Myasthenia Gravis
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Ankylosing Spondylitis
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Scleroderma
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Chronic Myofascial Pain Syndrome
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Torticollis
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Gout
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Osgood-Schlatter Disease
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Arthritis
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Artificial Joints / Special Equipment
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Scoliosis
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Compartment Syndrome
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Whiplash
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Hereditary/Congenital Deformity
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Osteoarthritis
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Baker's Cyst
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Sinus Problems
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Degenerative Disk Disease
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Jaw Pain (TMJD)
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Osteomalacia
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Bone Disease
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Spasms / Cramps
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Dislocation
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Osteoporosis
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Other Musculoskeletal
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Respiratory
Chronic Cough
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COPD
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Emphysema
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Respiratory Conditions
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Shortness of Breath
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Asthma
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Other Respiratory
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Miscellaneous
Surgical Pins or Wire
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Prenatal (check boxes to enter details below)
Due Date
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Massage Goals
Address Health Issues
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Balance
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Flexibility
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Increase Well-Being
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Injury Rehabilitation
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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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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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Allergy
Miscellaneous
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