Confidential Patient Case History Form PDF Details

When stepping into a healthcare provider's office, particularly for massage therapy, one typically encounters various forms of paperwork that need to be filled out before treatment can begin. Among these, the Confidential Patient Case History Form plays a crucial role in ensuring that the care provided is tailored to the specific needs and health conditions of the patient. Designed to gather comprehensive personal and medical information, this form asks for basic identifiers like name, address, and contact information, while also diving deep into medical history details. Patients are prompted to disclose conditions ranging from cardiovascular and respiratory issues to digestive ailments and beyond. It meticulously inquires about family medical history, surgeries undergone, medication intake, and even lifestyle factors such as levels of physical, mental, and emotional satisfaction. This meticulous compilation of data not only aids therapists in customizing treatment plans but also flags any potential risks or precautions to be considered during therapy. Significantly, it underscores the importance of mutual understanding and agreement between the therapist and patient regarding the scope of treatment, clearly stating the non-diagnostic role of massage therapists. By providing a thorough snapshot of the patient's health, this form acts as a cornerstone for effective and safe therapeutic practices.

QuestionAnswer
Form NameConfidential Patient Case History Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesProv, CVA, case history format pdf, RMT

Form Preview Example

Update 1

Update 2

Confidential Patient Case History Form

Please print clearly

 

 

Date __________________

Name _____________________________________________________

Male

Female

Address __________________________________

City _____________________ Prov ____________

Postal Code _______________ Home Phone: ____________________ Work Phone: ___________________

Birth Date: ________(m) ________(d) ________(y)

Occupation: _______________________________

Medical Doctor: ___________________________

Doctor Phone #: ____________________________

How did you hear about us? __________________________________________________________________

Please indicate conditions you are experiencing or have experienced:

Cardiovascular

Respiratory

Digestive

High blood pressure

Asthma

Constipation

Low blood pressure

Bronchitis

Chrones Disease

Chronic congestive heart failure

Emphysema

Colitis

Heart attack

Chronic Cough

Irritable Bowel Syndrome

Phlebitis / varicose veins

Shortness of breath

Ulcers

Stroke / CVA

 

 

Pacemaker or similar device

Is there a family history of any of the

 

Heart disease

above? Yes No

 

Dizziness / vertigo

 

 

Seizures

 

 

Is there a family history of any of the above?

 

 

Yes No

 

 

Head and Neck

Muscle/Joint

Other

History of headaches

Neck

Loss of sensation

History of migraines

Back (lower)

Where? ____________________

Vision problems

Back (mid)

Diabetes

Vision loss

Back (upper)

Onset: _____________________

Ear problems

Shoulders

Type: ______________________

Hearing loss

Elbow

Allergies / hypersensitivity

 

Wrist / Hand

What? _____________________

 

Hip

Epilepsy

 

Knee

Cancer

 

Ankle / Foot

Type/Location: _______________

 

Spine

Arthritis

 

 

Is there a family history of

 

 

arthritis? Yes No

 

 

Hemophilia

Women

Infectious Conditions

Fibromyalgia

Pregnancy

Skin Conditions

Chronic fatigue

Due Date: ______________________

Describe: ______________________

Scoliosis

Previous pregnancy complications

Respiratory Conditions

Polio / Post Polio

_______________________________

Describe: ______________________

Osteoporosis

_______________________________

Hepatitis

Men

 

Menopausal problems

 

Enlarged Prostate

_______________________________

Skin Conditions

Libido Issues

Menstrual problems

Eczema

Other

_______________________________

Psoriasis

_________________________

Gynecological conditions

Rash

 

Describe: _______________________

Warts

 

 

Open Sores

 

 

 

 

Do you have any medical conditions not listed above? Yes No

If yes, please describe: ________________________________________________________________________

Do you have any internal wires, artificial joints, pacemakers or special equipment that we should be aware of? Yes No

___________________________________________________________________________________________

Please circle areas which are currently causing you symptoms of pain, stiffness, numbness or other forms of discomfort

Face

Upper back

Arm(s)

Hand(s)

Thigh(s)

Ankle(s)

Neck

Mid back

Elbow(s)

Finger(s)

Knee(s)

Feet

Shoulder(s)

Lower back

Wrist(s)

Hip(s)

Leg(s)

Toe(s)

Chest

Ribs

Tailbone

For what condition or reason are you seeking treatment today? ____________________________________

___________________________________________________________________________________________

Have you seen any other health care professional(s) for this condition or reason? Yes No If yes whom? ________________________________________________________

Have you ever been involved in any motor vehicle accidents? Yes

No Date:___________________

Have you been involved in any other accidents?

Yes

No Date:___________________

Have you ever been knocked unconscious?

Yes

No Date:___________________

Briefly list any surgeries you have undergone, for what and when.

___________________________________________________________________________________________

___________________________________________________________________________________________

Are you presently taking any prescribed medication(s)? Yes No

If yes, please list the medication(s) and the condition(s) for which it is being used if known.

___________________________________________________________________________________________

___________________________________________________________________________________________

Have you previously received massage therapy treatments?

Yes No

If yes, were you treated:

At this clinic From an RMT Other

Please circle on the following scales the extent to which you are currently satisfied with the following:

(5 represents total satisfaction, 1 represents little or no satisfaction)

Physical health & fitness

5

4

3

2

1

Mental & emotional happiness

5

4

3

2

1

Energy level

5

4

3

2

1

Diet

5

4

3

2

1

Ability to relax

5

4

3

2

1

I acknowledge that the Massage Therapist is not a physician and does not diagnose illness or disease or any other physical or mental disorder. I clearly understand that massage therapy is not a substitute for a medical examination. It is recommended that I attend my personal physician for any ailment that I may be experiencing. I acknowledge that no assurance or guarantee has been provided to me as to the results of the treatment.

I acknowledge and understand that the Massage Therapist must be fully aware of my existing medical conditions. I have completed my medical history form as provided by my Massage Therapist and disclosed all of those medical conditions affecting me. It is my responsibility to keep the Massage Therapist updated on my medical history. The information I have provided is true and complete to the best of my knowledge.

_____________________________________________

____________________

________________________

Signature

Date

Therapist Signature

_____________________________________________

____________________

________________________

Signature

Date

Therapist Signature

_____________________________________________

____________________

________________________

Signature

Date

Therapist Signature

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