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
_______________________________		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

Question	Answer
Form Name	Confidential Patient Case History Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	Prov, CVA, case history format pdf, RMT

Confidential Patient Case History Form – Fill Out and Use This PDF

Confidential Patient Case History Form PDF Details

Form Preview Example

Confidential Patient Case History Form isn’t the one you’re looking for?

Confidential Patient Case History Form – Fill Out and Use This PDF

Confidential Patient Case History Form PDF Details

Form Preview Example

Confidential Patient Case History Form isn’t the one you’re looking for?

Related Documents