Name - Oakbank Massage Therapy

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Name - Oakbank Massage Therapy
Patient
Introduction
622 Main Street, Oakbank MB R0E 1J0
(Please fill out both sides)
Name
_________________________
Home phone
___________________
Address
_________________________
Work phone
___________________
City / town
_________________________
Other phone
___________________
Postal Code
_________________________
Physician’s name
___________________
Date of last physical
___________________
phone # ___________________
Date of birth (D/M/Y) ___________________
address
Occupation
___________________________
_________________________
___________________
How did you hear about Oakbank Massage Therapy?
Referred by ___________________________________________________________________
Other
___________________________________________________________________
How would you describe your lifestyle? (please check one)
Inactive
Active
Very Active
What type of exercise do you incorporate into your lifestyle? _______________________________
_________________________________________________________________________________
Have you been treated by a Physician in the last 5 years for any of the following?
(Please check all that apply)
Hypertension
Conditions of respiratory system
Heart Conditions
H. I. V.
Cholesterol
Skin conditions or irritations
Surgery
Allergies
Nervous Disorders
Other
Headaches
_______________________
Temporal Mandibular Joint
Whiplash
Multiple sclerosis
Back pain
Diabetes
Stomach or Digestive track disorders
Fainting or dizziness
Circulatory conditions
Cancer
R
L
L
R
Patient
Introduction
622 Main Street, Oakbank MB R0E 1J0
(Please fill out both sides)
Are you here regarding a specific injury or condition? ____________________________________
_________________________________________________________________________________
If yes please describe to your best ability. ______________________________________________
_________________________________________________________________________________
Describe what you expect from today’s visit. ____________________________________________
_________________________________________________________________________________
Are you presently taking any medication or natural remedies? If so, please list. _________________
_________________________________________________________________________________
Have you been treated by any of the following in the last 2 years?
Chiropractor
Naturopath
For what condition(s)? _______________________
Physiotherapist
__________________________________________
Massage Therapist
__________________________________________
Osteopath
__________________________________________
Other _________________________
__________________________________________
Do you have any past history of any of the following? Please check all that apply.
Headaches
Arm pain
Pain in the chest
Upper back pain
Leg pain
Irritation of the eyes
Lower back pain
Pain of the abdomen
Other __________________________
Does your family have any of the following conditions? Please check all that apply.
Diabetes
Multiple sclerosis
Respiratory disorders
Back pain
Liver disorder
Cancer
Headaches
Neurological conditions
Heart condition
Hypertension
The information contained on this form is true to the best of my knowledge.
Signed ______________________________________
Date _____________________________
I give my permission that my therapist may obtain and submit reports regarding my condition
to/from my physician as may be required.
Signed ______________________________________
Date _____________________________

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