Health History Form

    Touch Works London

    ...with mindfulness and integrity
    RMT
    637 Wellington St., London On N6A 3R8

    HEALTH HISTORY FORM

    The information request below will assist us in treating you safely. Feel free to ask any questions about the information being requested. All information will be kept confidential unless allowed or required by law. Your written permission will be required to release any information.

    How did you find out about our clinic:

    Friend/RelativeHealth Care PractitionerGoogleYellow PagesOther

    Have you received a massage before?

    YesNo

    Please indicate conditions you are experiencing or have experienced:

    Cardiovascular

    High Bld PressureLow Bld PressureChronic Congestive Heart FailureHeart AttackPhlebitis/Varicose VeinsStroke/CVAPacemaker or Similar DeviceHeart Disease

    Respiratory

    Chronic CoughShortness of BreathBronchitisCOPDAsthmaEmphysemaPneumonia

    Infections

    ShinglesPlantar WartsHepatitisSkin ConditionsTBHerpes

    Head/Neck

    History of HeadachesHistory of MigrainesVision ProblemsVision LossEar ProblemsHearing LossWhiplashConcussion

    Women

    Pregnant

    , due date:  

    Gynecological Issues

    Muscular/bones/joints

    SprainStrainsBroken Bone/sShoulder SeparationHerniated DiscJoint Replacement, where, when

    Other Conditions

    Loss of SensationArthritis OA or RADiabetesAllergiesEpilepsyCancerOsteoporosis

    Do you have any other medical conditions e.g., digestive conditions, hemophilia, HIV/AIDS, mental illness?

    YesNo

    Have you ever been in an accident?

    Motor VehicleOther
    When?


    Over the counter drugs you are presently taking e.g. Advil, Tylenol, Aspirin
    Taken Today?
    YesNo
    Are you under any specialist's care?
    NoYes
    Name:
    Present Health Care:
    ChiropracticChinese MedicineNaturopathy/HomeopathyOsteopathPhysiotherapist
    If you have a specific condition/injury that you are experiencing please complete the following:

    Level of discomfort:

    mild 12345678910 severe
    ConstantIntermittentCertain MovementDull PainAchySharp PainBurningTinglingSwelling

    CONSENT FOR MASSAGE THERAPY TREATMENT

    I have completed an accurate health history and agree to make known to the therapist should there be any changes to my health including medication changes. I understand I can ask any questions and that if at any time I feel uncomfortable I can ask the therapist to stop or alter the massage. Should I experience any unusual sensations during the massage I will let the therapist know.

    Notes:
    Health History Update:

    Please be sure to check your spam for our response and whitelist our email address. Thank you!

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