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New Patient Paperwork: Massage Therapy
Please complete the following paperwork if you are a new registered massage therapy patient at Back to Health Wellness Centre.
The form should take around 20 minutes to complete.
Massage Therapy New Patient Paperwork
Step 1 of 9
11%
Disclaimer
*
This form takes approximately 30 minutes to complete. Please ensure that when you have the time to do so, you take the time to read and answer every question; including as many details as possible. THIS IS DONE FOR YOUR OWN SAFETY as our clinic assesses every patient according to their individual needs and uses different techniques and tools to do so!
I have read and agree to the disclaimer
No Scents Policy
*
At Back to Health Wellness Center we have a scents policy. This policy is for the health and comfort of the health care practitioners, employees and patients of Back to Health. Please avoid wearing perfumes, colognes and other personal hygiene products that have any scent. These scents can linger in the air as well as remain on the hands of the health care practitioners as many scents are not easily washed off.
Yes
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone (cell/primary)
*
Phone (home)
Phone (work)
Email
*
Current Date
*
Month
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Sex
*
Male
Female
Gender
*
Birth Date
*
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How did you find out about our clinic?
*
Who is your family physician?
What is your family physician's address?
Family physician's phone number
Emergency Contact Name
*
Emergency Contact Phone Number
*
What is your occupation?
*
What is your general health status?
*
Very good
Good
Neutral
Poor
Very Poor
What is your dominant hand?
*
Left
Right
What is your primary sleeping position?
*
Side
Back
Stomach
Do you smoke?
*
Yes
No
How much do you smoke per day?
Are you currently taking any medications or supplements?
*
Yes
No
Please list your medications and supplements below:
Do you take over the counter pain medication on a regular basis?
*
Yes
No
Please list the pain medications that you take.
Are you or are you possibly pregnant?
Yes
No
Expected due date:
Do you exercise regularily?
*
Yes
No
How many times per week do you exercise?
Please enter a number from
0
to
20
.
What are your recreational activities?
Do you have any internal pins, wires, artificial joints or other special equipment (such as a pacemaker or hearing aid)?
*
Yes
No
Please explain:
Have you ever seen a Massage Therapist?
*
Yes
No
What is their name?
When was your last treatment?
Month
1
2
3
4
5
6
7
8
9
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11
12
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1
2
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23
24
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26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
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1963
1962
1961
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1936
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1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Have you ever been in a motor vehicle accident, sustained an athletic injury, or other trauma?
*
Yes
No
Please list the dates and any injuries you suffered.
Have you ever been hospitalized?
*
Yes
No
Please list the dates and reasons for your hospitalization.
Have you ever had surgery?
*
Yes
No
Please list the dates and reasons for your surgeries.
What is the primary purpose of your visit?
*
What started this condition?
*
When did this condition begin?
*
What aggravates this condition?
*
What relieves this condition?
*
Once your primary problem is fixed, are there any other problems that you would like to have treated?
Do you have any new wounds, recent tattoos, sunburns, rashes, tender scars, etc. in the areas that you wish to have treated?
*
Yes
No
Have you received treatment from other healthcare providers for this condition?
*
Yes
No
What are their names and what type of healthcare providers are they?
Please select all current symptomatic areas in your body.
*
Head
Neck
Shoulder
Upper arm
Elbow
Forearm
Hands
Upper back
Chest
Midback
Lower back
Hip
Upper leg
Knee
Lower leg
Ankle
Foot
Other
Please feel free to elaborate on your symptomatic areas.
Have you ever been diagnosed with or experienced any of the following circulatory or respiratory problems?
*
Chronic congestive heart failure
Heart disease
Other heart condition
High blood pressure
Low blood pressure
Varicose veins
Phlebitis
Deep vein thrombosis
Raynaud's disease/phenomenon
Buerger's disease
Chronic cough
Bronchitis
Asthma
Emphysema
Shortness of breath
None of the above
Have you ever been diagnosed with or experienced any of the following nervous system problems?
*
Epilepsy
Multiple sclerosis
Cerebral palsy
Parkinson's
Nerve lesion
Sciatica
Carpal tunnel syndrome
None of the above
Have you ever been diagnosed with or experienced any of the following musculoskeletal problems?
*
Scoliosis
Bone or joint disease
Arthritis
Joint instability
Tendinitis
Fractured bones
Jaw pain (TMJ)
Whiplash
None of the above
Have you ever been diagnosed with or experienced any of the following skin problems?
*
Sensitivities to oils, lotions, detergents
Other allergies or hypersensitivities
Irritated skin conditions
Contagious conditions
Frostbite
Lack of sensation
None of the above
Have you ever suffered from a heart attack?
*
Yes
No
Please list the date(s) of your heart attack(s).
Have you ever suffered from a stroke?
*
Yes
No
Please list the date(s) of your stroke(s).
Have you ever been diagnosed with or experienced any of the following general health problems?
*
Cancer/Tumors
Undiagnosed lump
Diabetes
Kidney problems
Liver problems
Drug/alcohol addiction or withdrawal
Infectious conditions (hepatitis, HIV, etc.)
Eating disorder
Recent abortion or vaginal birth
Loss of vision or hearing
None of the above
Please list any other conditions not listed and provide details as necessary.
Our clinic fee schedule can be found here: back2health.mf-dev.ca/clinic-fee-schedule/
*
I have read and agree to the clinic fees
I hereby declare that all of the above information is correct, and if it should change, it is my responsibility to notify the therapist of these changes at the next scheduled appointment.
*
I agree with the above statement.
Our Clinic
Patients
Visiting the Centre
Clinic Fee Schedule
Do I Need a Referral?
Book an Appointment
Patient Forms
Your Report of Findings
Photos and Videos
Videos
Careers – Join our Team!
Services
Chiropractic
Active Release Technique
Acupuncture
Cranial Therapy
Naturopathic Care
Physiotherapy
Orthotics Ottawa
Gait Analysis for Better Foot Health
Massage Therapy
Additional Services and Articles
What We Treat
Products & Supplements
Patient Stories