CONFIDENTIAL PATIENT INTAKE FORM
Adele Wong, RMT
Name:
Address:
City:
Postal Code:
Occupation:
Computer Use?
Date of Birth (mm/dd/yyyy):
Phone:
Email:
Emergency Contact:
Major Work Activity: Sit / Stand / Physical Labour
Yes / No
# of Hours per Day?
Reason for Seeking Treatment?
(if being claimed by ICBC or WCB, please provide claim #)
Current Level of Pain/Discomfort, 1-10 (1 = low; 10 = high)
Please indicate areas of pain/discomfort:
How long have you had this condition?
How did it start?
Please rate your current lifestyle factors, 1-5 (1 = poor; 5 = excellent)
Quality of sleep:
# hours per night?
Stress level:
Exercise habits:
Type?
# of times per week?
Past or Present Treatments (circle all that apply):
MD / GP
Chiropractic
Massage Therapy
TCM / Acupuncture
Physiotherapy
Other:
Please list any Medications and/or Painkillers you presently take:
Known Allergies (medications, foods, seasonal, pets, etc):
Past Major Accidents or Injuries?
Please specify (including date):
Auto / Sport / Work / Surgery / Other:
MEDICAL CONDITIONS (P = Past; C = Current)
High / Low Blood Pressure
Headaches / Migraines
Jaw / TMJ Pain
Sprains / Strains
Repetitive Strain / Tendonitis
Bone Fracture
Joint Dislocation
Skin Condition / Eczema
Corrective Lenses
Pregnancy
Hyper / Hypo -thyroidism
Diabetes I / II
Respiratory / Asthma
Irritable Bowel / Colitis
Kidney
Arthritis / Gout
Head Injury / Concussion
Spinal Injury / Disc Hernia
Swelling / Edema
Fibromyalgia / Chronic Pain
Heart
Stroke / Aneurysm
Seizures / Epilepsy
Dizziness / Fainting
Implants
Rods / Pins / Plates / Screws
Cancer
Hepatitis
HIV
Other:
PLEASE READ THE FOLLOWING WAIVER:
1. Informed Consent: By signing below, I consent to receiving Massage Therapy. I understand and have
discussed with the Registered Massage Therapist that there may be risks related to receiving a massage
treatment. I do not expect the therapist to be able to anticipate and explain all risks and complications. I
understand the therapist will proceed with a treatment plan that they feel is best suited for my current
condition. I further understand that in no way is Massage Therapy a cure for any condition nor is it meant to
substitute any other medical treatments.
2. Privacy Statement: By signing below, I authorize the collection, use and disclosure of personal information,
as defined in the Personal Information and Privacy Act (PIPA), required for treatment and or any related
administrative purpose. I understand that all my personal information is confidential, and must be treated in
accordance with PIPA.
3. Scheduled Treatment Time: Each visit includes administration, assessment, evaluation, treatment and
patient education. During the initial visit, assessment and evaluation will be more detailed and requiring
more of the treatment time than subsequent visits. Subsequent visit assessment time varies with presenting
condition.
4. Fee Policy: The patient or guardian is always responsible for treatment fees at the time of the appointment.
5. Cancellation Policy: In consideration of your fellow patients and your therapist, a minimum of 24 hours’
notice is required to change or cancel an appointment by phone call. Appointments missed or cancelled on
less than 24 hours’ notice are subject to the full service fee.
In signing, I confirm that I have read and understood the above stated and agree to the terms set out.
Patient/Guardian Signature:
Confidential Patient Intake Form
Date:
Adele Wong, RMT