Return	Confidential Massage Therapy Patient Case History Form
When complete, please print this form and bring it with you to your first appointment.

Patient Information
First Name		Last Name
Street Address		Apartment
Town/City		Province	ON AB BC MB NB NF NS NT NU PE QU SK YT	Postal Code
Home Phone		Work Phone
E-Mail

Birth Date

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Age

Sex

Male Female

Where did you first hear about the clinic? (please be specific)
Name of Medical Doctor

Medical History
Present Complaint(s)
Are you in pain now?	Yes No
Please locate the pain on the diagrams below: X for pain; O for stiffness; N for numbness

Have you had any previous treatment for the above complaint?
Massage Therapist      Chiropractor      Physiotherapist      Medical Doctor      Other
Do you anticipate having to take any medications prior to your arrival to the clinic?	Yes No
If yes, please list
Are you on any medication right now?	Yes No
If yes, which one(s)?
Are you allergic to oils or creams?	Yes No
If yes, which one(s)?
Do you stretch regularly?	Yes No
Do you exercise regularly?	Yes No

Previous Injuries / Serious Illnesses
1. Type		Date
Explain
2. Type		Date
Explain
3. Type		Date
Explain

Please indicate if you have any of the following conditions:
head / neck current previous   tension headache sinus headache migraine vision problems contact lenses earaches hearing problems herniated disk respiratory current previous   asthma chronic cough shortness of breath bronchitis emphysema digestive / urinary current previous   digestive problems constipation liver / gall bladder kidney / bladder colitis / crone's diabetes ulcers	cardiovascular current previous   high blood pressure low blood pressure poor circulation heart disease stroke varicose veins phlebitis pacemaker muscle / joint pain current previous   neck lower back mid back upper back shoulders hip: left right leg: left right knee: left right ankles: left right special note pins wires artificial joints / limbs

infectious conditions current previous type tuberculosis aids / hiv hepatitis infectious skin condition(s) skin current previous type / location skin condition(s) bruise easily plantar warts loss of sensation eczema / psoriasis other conditions epilepsy fibromyalgia cancer arthritis hemophilia osteoporosis scoliosis chronic fatigue polio / post-polio

Female
Are you pregnant?	Yes No

Date	Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Signature of Patient / Guardian

Please complete this form prior to arriving at our office. If you have any questions, please do not hesitate to contact our office at 905-898-8098, or wait until your appointment time. Thank you for choosing Dr Laura Foster & Associates for Massage Therapy care.