Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Health History Form
Document related concepts
Transcript
Health History Form Meagan Michalski, RMT An accurate health history is important to ensure that it is safe for you to receive a massage treatment. If your health status changes in the future, please inform you therapist. All information gathered for this treatment is confidential except as required or allowed by law or except to facilitate diagnosis (assessment) or treatment. You will be asked to provide written authorization for release of any information. PERSONAL INFORMATION Name: _____________________________________________________ Address: __________________________________________________ City: ___________________________ Postal Code: _____________ Today’s Date: ______________________________________ Birthdate: __________________________________________ Phone Number: ____________________________________ Business Number: _________________________________ Height (inches): _____________ Weight (lbs): _____________ Who referred you? _______________________________________ Emergency Contact: _______________________________ Primary Physician: _______________________________________ Emergency Contact #: _____________________________ Physician Address: _______________________________________ Physician Phone Number: _______________________________ Other Health Care Practitioners: Chiropractor Physiotherapist Naturopath Other: _________________ General Health Status: POOR FAIR GOOD EXCELLENT Occupation: _______________________________________________ Recreational Activities: ____________________________ Primary Occupation Activities: __________________________________________________________________ Primary Complaint: _______________________________________________________________________________ Pain Scale: 0 1 2 3 4 5 6 7 8 9 10 HEALTH HISTORY Please indicate all current/ongoing (C/O) and past conditions you have experienced Head/Neck C/O Past Whiplash ☐ ☐ Headaches ☐ ☐ Migraine ☐ ☐ Concussion ☐ ☐ Ringing in the Ears ☐ ☐ Hearing Loss ☐ ☐ Vision Problems ☐ ☐ Brain Injury ☐ ☐ TMJ (Jaw Pain) ☐ ☐ Other: __________________________________ Respiratory/Lungs C/O Past Digestive C/O Past Asthma ☐ ☐ Constipation ☐ ☐ Bronchitis ☐ ☐ Diarrhea ☐ ☐ Emphysema ☐ ☐ Crohn’s Disease ☐ ☐ Pneumonia ☐ ☐ Irritable Bowel Syndrome☐ ☐ Shortness of Breath ☐ ☐ Ulcers ☐ ☐ Sinusitis ☐ ☐ Diverticulitis ☐ ☐ Frequent Colds ☐ ☐ Nausea ☐ ☐ Recurrent Lung Infection ☐ ☐ Chronic Cough ☐ ☐ Family History of Above: _________________ Other:_____________________________________ Other: __________________________________________ Cardiovascular C/O Past High Blood Pressure ____/_____ ☐ ☐ Low Blood Pressure ____/_____ ☐ ☐ Heart Attack ☐ ☐ Chronic Congestive Heart Failure ☐ ☐ Chest Pain/Angina ☐ ☐ Stroke ☐ ☐ Pace Maker or Similar Device ☐ ☐ Phlebitis ☐ ☐ Hemophilia ☐ ☐ Heart Disease ☐ ☐ Poor Circulation ☐ ☐ Congestive Heart Failure ☐ ☐ Family History of Above: __________________________ Other: _______________________________________________ Nervous System Spinal Cord Injury Numbness/Tingling Sensory Change/Loss Sciatica TOS Seizures Multiple Sclerosis Cerebral Palsy Epilepsy Carpal Tunnel Muscular Dystrophy C/O ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Past ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Other: ____________________________________ Infections C/O Hepatitis ☐ Type: ___________________ Infectious Skin ☐ Conditions ☐ TB ☐ HIV ☐ Past ☐ ☐ ☐ ☐ ☐ Other: ____________________________ 1 Disease/Condition C/O Past Cancer Benign/Malignant ☐ ☐ Type/Location: ____________________________ Treatment: _________________________________ Fibromyalgia ☐ ☐ Chronic Fatigue Syndrome ☐ ☐ Allergies ☐ ☐ Diabetes (Type?) _______________ Onset: ______________________________________ Other: ______________________________________ Soft Tissue Joint Discomfort or Pain C/O Head/Jaw ☐ Neck ☐ Shoulder ☐ Arm ☐ Wrist/Hand ☐ Back ☐ Hips ☐ Legs ☐ Knees ☐ Ankles/Feet ☐ Tendonitis ☐ Strain/Sprain ☐ Poor Posture ☐ Other: ___________________________________________ Skin C/O Past Eczema ☐ ☐ Dermatitis ☐ ☐ Acne ☐ ☐ Frostbite ☐ ☐ Psoriasis ☐ ☐ Sensitive Skin ☐ ☐ Rash/Eruptions ☐ ☐ Cold Sores ☐ ☐ Herpes ☐ ☐ Other: ___________________________ Past Bone/Joint C/O Past Dislocation ☐ ☐ Fracture ☐ ☐ Arthritis (RA/OA) ☐ ☐ Family History of Arthritis: _______________ Degenerative Disc ☐ ☐ Disease Prolapsed/Herniated ☐ ☐ Disc Other: _______________________________________ Women Only C/O Past Pregnancy ☐ ☐ Vaginal Birth/Abortion ☐ ☐ Weeks Pregnant: ___________________ # of Children (not including this pregnancy) ________________ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Other: _________________________________ Current medication or supplements and what condition do your medicine/supplements treat: _____________________________________ _________________________________________________________________________________________________________________________________________________ Surgical operations or Hospitalizations (please indicate date of occurrence): _________________________________________________________ _________________________________________________________________________________________________________________________________________________ Major injuries/accidents including fractures (please indicate date of occurrence): ___________________________________________________ _________________________________________________________________________________________________________________________________________________ Of special note: (pins, wires, plates, artificial joints, etc.) Please explain: _______________________________________________________________ _________________________________________________________________________________________________________________________________________________ List any areas that you do NOT want treated: _____________________________________________________________________________________________ Are you physically active? Yes ☐ No ☐ How often and Type? _______________________________ Previous Massage Experience Yes ☐ No ☐ Good Sleeping Habits Yes ☐ No ☐ Regular Eating Habits Yes ☐ No ☐ Stress Levels High ☐ Medium ☐ PLEASE CIRCLE CURRENT SYMPTOMATIC AREAS YOU WANT TREATED Low ☐ Date: ________________________________________________________ Client Signature: ____________________________________________ Therapist Signature: ________________________________________ 2
