Massage Therapy Intake Form

* = Required Field
Personal Information
Name*
First Last
Address*
Street Address City Province Postal Code
Home Phone
Mobile Phone
Work Phone
Date of Birth*
Date Format: YYYY slash MM slash DD
E-mail Address*
Occupation*
Length of time in position*
Emergency Contact
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Phone*
How did you hear about our clinic?
How did you hear about our clinic?*
Doctors Name
Name
Social Media
- Facebook
- Instagram
- Twitter
Other
Doctor's Information
Family Physician's Name*
Doctor's Address*
Street Address City Province Postal Code
Family Physician Phone*
Family Physician Fax
Coverage Details (if applicable)
Primary Coverage
Insurance Company
Plan/Contract #
Certificate/ID #
Policy Holder's Name
Policy Holder's DOB (yyyy/mm/dd)
Date Format: YYYY slash MM slash DD
Health Questionnaire
The information requested below will assist us in treating you safely. Feel free to ask any questions about the information being requested. Please note that all information provided will be kept confidentially unless allowed or required by law. Your written permission will be required to release any information.
1. Location and Nature of Soft Tissue and/or Joint Discomfort*
2. Do you presently have or ever had any of the following? Check all that apply:
Cardiovascular*
- High Blood Pressure
- Low Blood Pressure
- Chronic congestive heart failure
- Heart Attack
- Phlebitis / varicose veins
- Stroke / CVA / TIA
- Heart disease
- None of the above
(Cardiovascular) Is there a family history of any of the above?*
- No
- Yes
(Cardiovascular) Yes, there is a family history of:
Respiratory*
- Chronic Cough
- Shortness of Breath
- Asthma
- Emphysema
- Bronchitis
- None of the above
(Respiratory ) Is there a family history of any of the above?*
- No
- Yes
(Respiratory) Yes, there is a family history of:
Infections*
- Hepatitis
- Skin Conditions
- TB
- HIV
- Herpes
- None of the above
Skin conditions:
Head / Neck*
- History of Headaches
- History of Migraines
- Vision Problems
- Vision Loss
- Ear Problems
- Hearing Loss
- None of the above
Other Conditions*
- Loss of Sensation
- Diabetes
- Onset Diabetes
- Allergies / Hypersensitivity
- Cancer
- Arthritis
- Epilepsy
- None of the above
(Other Conditions) Where?
(Other Conditions) To what? Type of reaction?
Is there a family history of arthritis?*
- No
- Yes
- Don't know
(Arthritis) Where?
Women
Pregnant?
- No
- Yes
Due Date*
Date Format: MM slash DD slash YYYY
Gynecological Conditions?
- No
- Yes
(Gynecological Conditions) What?
3. Please give a list of all surgeries, past injuries or major dental work you have had:
4. Please provide a list of your current medications and conditions it treats:
5. Do you have any other diagnosed diseases or medical conditions? (eg. Digestive conditions, hemophilia, osteoporosis, mental illness)*
- Yes
- No
Please describe
6. Do you have an internal pins, wires, artificial joints or special equipment?*
- Yes
- No
Massage Survey
To tailor your massage specifically to your needs please answer the following questions:
1. Have you ever had a massage before?*
- Yes
- No
2. What pressure would you like the Massage Therapist to use during the massage?*
- Light
- Moderate
- Deep
If you are unsure of the pressure that you require, please discuss this your therapist
3. During my massage I prefer:*
- Quiet & relaxing, having the therapist check in occasionally, & leaving education until the end
- Chat & catch up with my therapist
- A little of both
Consent
Please read the following carefully and fully:
Palermo Physiotherapy and Wellness Centre is a multidisciplinary health care provider where the practitioners work in conjunction to provide you, the patient, thorough care and treatment. All staff members are required to sign a confidentiality form with regards to your personal information and are trained in appropriate use and protection of your information.
All handling of your information is compliant with existing college guidelines and provincial and federal legislation. Our clinic uses your information to ensure you receive the best care.
I give Palermo Physiotherapy and Wellness Centre my consent to release / obtain information from the following individuals with respect to:*
- Physician(s)
- Insurer
- Family Memeber
- Employer
- Other
- None of the above / not applicable
Physician(s)
Insurer
Family Member Name
Employer
Other
E-mail
- I give permission for Palermo Physiotherapy and Wellness Centre to use the email provided to send reminder emails of scheduled appointments, for paperless billing and for information regarding changes in clinics offerings.
Payment Information*
- I understand that payments for services at Palermo Physiotherapy and Wellness Centre are my responsibility after every service is received. If my claim is to be submitted to an outside agency for payment, and for any reason the third party payer, such as insurance or employer denies and/or refuses to pay for the full amount I am billed, I am responsible for payment.
Cancellation of Appointment*
- I understand that Palermo Physiotherapy & Wellness requires a minimum of 24 hours notice for any appointment cancellations. Should you give less than 24 hours notice, a $25.00 cancellation charge may be charged. Your appointment time has been reserved specifically for you. Should you book an appointment and not to attend, you are responsible to pay for the entire cost of the appointment.
Informed Consent for Assessment and Treatment (Massage Therapy)
During your initial visit, the Massage Therapist discuss treatment recommendations and techniques. Massage Therapy involves the manipulation of the soft tissues of the body, skin, muscle, ligaments and connective tissues, using techniques to produce therapeutic results.
With Massage Therapy, the client disrobes to their comfort level, and lies on a table between two sheets. Only the areas of the body being directly treated are uncovered at one time. If at any time you are uncomfortable with the pressure or technique being used, you can ask the therapist (i.e. to decrease or increase pressure, etc). You can also stop the treatment at any time
Rendering of Evaluations, Treatments and/or Services*
- I hereby consent to the rendering of evaluations, treatments and / or services as communicated by the Massage Therapist named below. My consent is voluntary and I intend this consent to cover the entire course of assessment/treatment commencing on the date indicated below. I understand that I may ask questions at any time regarding the assessment and treatment and that this consent may be withdrawn at any time.
Patient/Guardian Name*
Date (yyyy/mm/dd)*
Date Format: YYYY slash MM slash DD
Signature*
Phone
This field is for validation purposes and should be left unchanged.