Download Health History Form - All Sports and Wellness

All Sports and Wellness
110 Dartmouth road Bedford N.S. B4A 2L7
Phone: (902) 431-5224 Cell: (902) 830-7677
HEALTH HISTORY FORM
For your information :
An accurate medical history is important to ensure that it is safe for you to recieve a massage treatment .All information gathered
treatment purpose is confidential,except as required or allowed by law.If needed to be asked to provide written authorization for
release of any information to other health care practitioners to facilate assessment or treatment.
Name:___________________________________________ Date of birth :_______________________________________
Adress:_______________________________ City: _______________Postal Code : ________________________________
Phone N.(Home):______________________ (Cell) : ___________________ (Work):________________________________
E-mail Adress: _____________________________________Occupation:_________________________________________
General Practionner : ________________________________Who refered you ?__________________________________
Have you had a massage before ? Yes / No.
How would you decribe your health ? Good / Fair /Poor
Please describe your quality of sleep? Good / Fair /Poor. how much of water do you drink a day ? ____ Litres /Cups
Please list all forms and frequency of stress reduction activities,Hobbies,exercise,sports
Participation : ______________________________________________________________________
What is your primary complaint? ______________________________________________________
What symptoms are you experiencing ? _____________________ Are you experiencing any Night Pain ? : YES / NO
Chose one or more to describe your pain :Dull / Aching, Sharp / Sharp shooting, Numbness / Tingling ,
Throbbing / Diffuse
Mark “X”for conditions that pply to you
CARDIOVASCULAR
Aneurysm
High Blood Pressure
Low Blood Pressure
Heart Disease
Stroke
Varicose Veins
Phlebitis
Bruise Easily
Pace Maker
Muscle/Joint
Arthritis
Type:
Location:
Fibromyalgia
Pain/ stiffness in:
Head
Neck
Jaw
Back
Low, Mid, Upper
RESPIRATORY
Bronchitis
asthmas
Emphysema
Sinusitis
Tuberculosis
Breathing Problems
Specify:
SKIN
Plantar Warts
Eczema
Psoriasis
Fungal Infection/ Athletes
Foot
Herpes Simplex
Skin Condition
Specify:
Nervous
Multiple Sclerosis
Seizure/ Epilepsy
Carpel tunel Syndrome
Altered Sensation:
Where:
Digestive
Other
Enviromental Illness
Diabetes
HIV/AIDS
Cancer
Chronic Fatigue Syndrome
Women Only
Menopausal problems
Pregnant
Due Date:
Arms/Hands
Other:
Legs/Feet
Endometriosis
Osteoporosis
Others (Specify):
Other:
SURGERIES
PREVIOUS INJURIES:
Type:
TYPE:
Type:
DATE:
SPECIAL NEEDS
OTHER MEDICAL CONDITIONS
CURRENT MEDICATIONS: (including aspirin,Ibuprofen, etc)
Type:
For:
Type:
For:
ANY PIN, WIRE IMPLANTS, ARTIFICIAL JOINT? LIST:
ANY ALLERGIES?
Section
Painful Menstruation
Last Taken
Last Taken
All Sports and Wellness
110 Dartmouth road Bedford N.S. B4A 2L7
ADNAN RASSI, RMT 06086
Phone: (902) 431-5224 Cell: (902) 830-7677
INFORMED CONSENT TO MASSAGE THERAPY TREATMENT
By signing below, I verify that the information given on the accompanying Health History
form is true and accurately reflects Health status change in the future.
I understand that, as in health care, in the practice of massage therapy there are some very
slight risks to treatment including, but not limited to, aggravation of symptoms and residual
muscle sorness, i do not expect the massage to be able to anticipate and explain all risks and
complications and I wish to rely on the massage therapist to exersice judgment during the
course of treatment, I understand that the beneficial effects and possible risk factors of
massage therapy in general and the specific treatment of my condition will be explaind to
me.
I intend this consent to apply to all my recent and future massage therapy treatments. I
understand that this consent(undress your comfort level, get ready between the sheet,
question will be asked by the therapist about drapping and pressure,patient allow to ask
question at any time during treatment,benefit of the treatment decrease pain and increase
range of motion, side affects you may feels soreness for couples of days so you should
increase fluid intake and do your home care exersices,treatment can be modified or
withdrawn by me at any time.
Appointments: Your appointment time is reserved especially for you. If you find it necessary
to reschedule your appointment, a minimum of 24 hours is required so that others who
need an appointment may be accomodated. Otherwise, you may be billed for your missed
appointment.
PATIENT FEES
We accept Cash, Personal Cheques, Debit, Visa, Or Master card
30 Minutes
60 Minutes
75 minutes initial Assessment $ 80.00
$ 50.00
45 Minutes
$ 80.00
90 Minutes
There is a $25 charge for all NSF Cheques
Printed Client’s Name:___________________________________
Signature of client (Or Parent Guardian):___________________
Date:__________________________
$ 65.00
$ 120.00