Tc MacIntyre RMT

Massage Intake Forms

PATIENT HISTORY:
NAME: ___________________________________ PHONE: _________________________________
HOME

BUS

CELL

ADDRESS: __________________________________________________________________________
POSTAL CODE:__________________

BIRTH DATE: ________________________

REFERRED BY: _______________________________ IS THIS A WORKPLACE INJURY? YES / NO

Please note that we do not see WCB cases

EMAIL ADDRESS: ______________________________________________________________

OCCUPATION: ____________________________ EMPLOYED BY: ________________________
CONTINUOUS POSTURE:

SEATED

STANDING

REPETITIVE MOVEMENT: LIFTING TYPING

BENT FORWARD

BENT BACKWARD

________________________________________

PHYSICIAN: ______________________________ PHONE: _______________________________

ADDRESS: __________________________________________________________________________
DATE OF LAST EXAMINATION: ________________ ARE YOU PREGNANT:

YES

NO

IF YOU OR ANY OF YOUR FAMILY HAVE BEEN TREATED FOR ANY OF THE FOLLOWING CONDITIONS, PLEASE INDICATE
WITH:

1 = YOURSELF
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___

2 = FAMILY

JOINT REPLACEMENT
ARTHRITIS (OA, RA)
FRACTURE; _________
KIDNEY DISORDER
HEMORRHOIDS
ABDOMINAL PAIN
HEADACHES / (MIGRAINES)
THYROID PROBLEMS
EPILEPSY
SKIN CONDITIONS
EMPHYSEMA
BRONCHITIS
ASTHMA
PNEUMONIA
TUBERCULOSIS

___ WHIPLASH
___ NEUROLOGICAL DISORDER
___ TMJ / JAW DISORDER
___ DIGESTIVE PROBLEMS
___ HEART PALPITATIONS
___ FAINTING / DIZZINESS
___ CARDIOVASCULAR ISSUES
___ CIRCULATORY ISSUES
___ BLOOD PRESSURE;
HIGH / LOW
___ ANEMIA
___ HEMOPHILIA
___ GOUT
___ AIDS / HIV
___

CANCER:_________________
___ DIABETES; TYPE I / II
___ COMA / SEIZURES
___ LIVER DISORDERS
___ HIGH CHOLESTEROL
___ DEPRESSION
___ ANXIETY
___ HEPATITIS; TYPE ____
___ ALLERGIES:
__________________________
__________________________
__________________________
__________________________

ARE YOU CURRENTLY ON ANY MEDICATIONS?

____________________________________________________________________________________
HAVE YOU BEEN TREATED FOR THIS CONDITION BEFORE?

YES

NO

____________________________________________________________________________________________

www.elitesportperformance.com
p. 403-689-9889 112-10333 Southport Rd. S.W. Calgary, AB T2W 3X6 f. 403-668-4257

PERSONAL HABITS: DO YOU USE ANY OF THE FOLLOWING?

____________________________________________________________________________________________

DAILY OFTEN SPARINGLY NEVER

CIGARETTES ___
SWEETS ___

COFFEE ___

VITAMINS ___

TEA ___

ALCOHOL ___

ASPIRIN ___ SOFT DRINKS ___

HERBAL SUPPLEMENTS ___

____________________________________________________________________________________________
DRAWING OF AREAS OF CONCERN
_
MARK THE AREAS OF YOUR BODY WHERE YOU FEEL THE DESCRIBED SENSATIONS.
USE THE APPROPRIATE SYMBOL, INCLUDE ALL AFFECTED AREAS.
Ache

\\\\

Numbness

+++

Pins and Needles

ooo

Burning

bbb

Stabbing

sss

ARE YOU ATTENDING OUR OFFICE AS THE

RESULT OF SYMPTOMS DERIVED FROM
A MOTOR VEHICLE ACCIDENT? YES / NO
DO YOU HAVE ANY OTHER INFORMATION THAT WOULD BE BENEFITIAL TO YOUR TREATMENT?
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

THE INFORMATION THAT I HAVE PROVIDED IS ACCURATE TO THE BEST OF MY KNOWLEDGE. I

UNDERSTAND THAT DUE TO THE NATURE OF THE TREATEMENT I AM REQUIRED TO NOTIFY THE
THERAPIST AND MY FAMILY PHYSICIAN OF ANY CONTAGIOUS AND/OR COMMUNICABLE DISEASES.
NAME (PRINT): ________________________

SIGNATURE: ___________________

DATE: ____________

RMT: __________________________________________________________________

www.elitesportperformance.com
p. 403-689-9889 112-10333 Southport Rd. S.W. Calgary, AB T2W 3X6 f. 403-668-4257

I, (please print)_______________________understand that massage therapy

given at Elite Sport Performance is for the purpose of soft tissue injury relief.
I also understand that the therapist does not diagnose any physical or mental
disorders and as such will not prescribe medical treatments nor perform any
chiropractic adjustments.
It has been made clear to me that massage therapy is not a substitute for
medical or dental examinations and/or diagnosis and that it is recommended that
I see a physician for any ailment that I might have.
Because the massage therapist must be aware of any pre-existing conditions, I
have disclosed all of my known medical history and take it upon myself to keep
this information current and to update the therapist of any changes.

Signature_____________________________________
Date_________________________________________

www.elitesportperformance.com
p. 403-689-9889 112-10333 Southport Rd. S.W. Calgary, AB T2W 3X6 f. 403-668-4257