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COVID 19.
We Are Open With Enhanced Protocols and Safety Measures. This includes disinfecting, wearing breathable masks at all times, temperature checks, and liberal use of hand sanitizers.
Confidential Health History Form
Name
(Required)
First
Middle
Last
Phone (Home)
(Required)
Cell
(Required)
Phone (Work)
Email
(Required)
Address
(Required)
Street Address
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Date of Birth
(Required)
Day
Month
Year
Occupation
(Required)
First Time Massage Therapy
(Required)
Yes
No
Family Physician
(Required)
Address
(Required)
Phone
(Required)
Other Emergency Contact (Name)
(Required)
Phone
(Required)
Health History: Please check spaces below for any conditions that you are experiencing or have experienced, and inform the Massage Therapist about any changes in your condition immediately (before, during and after treatment).
Soft Tissue/Joints
tendonitis/bursitis
weakness
sprains/strains
arthritis OA/RA/other
fractures
herniated discs
Headaches
tension headaches
migraines
tooth/jaw/ear pain (circle)
head trauma
Accident/Injury
car accident
whiplash
Respiratory
chronic cough
shortness of breath
bronchitis
asthma
emphysema
pneumonia
sinus problem
COPD
Cardiovascular
high blood pressure
low blood pressure
heart attack
phlebitis
stroke/CVA
pacemaker
heart disease
angina
congestive heart failure
Infectious Disease
hepatitis A / B / C
turberculosis
HIV / AIDS
Skin
bruise easy
herpes
varicose veins
athlete's foot
warts / plantar warts
loss of sensation
Other Conditions
neurological conditions
epilepsy
diabetes
allergies
anaphylaxis
cancer
vision problems
hearing loss or tinnitus
constipation
diarrhea
Corhn's/colitis
other digestive conditions
insomnia / poor sleeping
kidney / bladder problems
hemophilia
fibromyalgia
osteoporosis
surgical implants
Women
pregnant
gynecological conditions
Respiratory
Surgery/Other Conditions? Y/N Type
Current symptoms
Current medication/treatments/health care programs (specify)
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