REGISTRATION FORM
*Cell# (Mandatory for text reminder)
*Name of Insurance Company *Benefit Year Period Health Claim Coverage $ Amount per benefit year: Health Spending Account (if any)Message Acupuncture Physiotherapy Chiropody Osteopathy Chiropractic Orthotics
Consent to Assessment/ Treatment
I hereby request and consent to the performance of physical, functional, and/or vocational assessment,treatment procedures on me by the massage therapist, the acupuncturist or other applicable practitioners.I have been informed with all the information and I feel that I fully understand what is involved in thepractice. The proposed assessment and/or treatment and what the possible consequences of not havingtreatment may be. I understand and acknowledge the possible risks and side effects if any./span>I acknowledge that for the purpose of integrated therapy the following areas may be addressed during the course of a treatment: head, neck, shoulders, upper chest, arms, back, hips, buttocks, hands, feet and legs.(Breast, Chest Wall Muscles, Buttocks, Upper Inner Thigh and Groin areas excluded). I understand the explanations and have no further questions. My consent is voluntary and I intend this consent form to cover entire course or assessment/ treatment for my present condition, commencing on the date indicated below. I understand that I may ask questions at any time and that this consent may be withdrawn in writing, at any time, except for actions already taken.
Client Signature
Date (Initial visit)
Health History Form
Please circle the conditions you are experiencing or have experienced:
Cardiovascular
high blood pressure
low blood pressure
chronic congestive heart failure
heart attack
phlebitis / varicose veins
stroke/CVA
pacemaker or similar device
heart disease
Is there a family history of any of the above? Yes No
Raspiratory
chronic cough
shortness of breath
bronchitis
asthma
emphysema
Is there a family history of any of the above? yes No
Infections
hepatitis
kin conditions
TB
HIV
herpes
Other Condition
Head/Neck
History of headaches
history of migraines
vision problems
Vision loss
ear problems
hearing loss
Women
Overall, how is your general health?
Primary Care Physician:
Address:
If Yes, please provide their name and address. Current Medications: Condition it treats: Are you currently receiving treatment from another health care professional?
YesYes No No If yes; for what
Injury Date Nature : Are you currently receiving treatment from another health care professional?
Yes No
Do you have any internal pins, wires, artificial joints or special equipment?
Yes No
Where ? What is the reason you are seeking massage therapy?
Health History Update
note: if no changes to health history, just update date each year; if there is a new form is required
Notes