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PERSONAL INFORMATION

Name*

Date*

Address*

City*

Postal Code*

Home

Cell

Occupation

Date of Birth

Height

Weight

e-mail

Dr.Name

Phone Number

Dr. Address

May I contact

Current Medications

Previous major Illnesses (Operations, Presence of Internal Pins)

Motor Vehicle accidents (please give dates)

Other medical conditions (e.g. Hemophilia, Diabetes, Cancer, Epilepsy)

Family history (major illnesses, operations, Arthritis)

Please indicate all conditions you are currently experiencing

Joint / soft tissue discomfort

Arms

Upper back

Mid back

Lower back

Degenerative discs

Feet

Hands

Hips

Jaw

Knees

Legs

Neck

Sciatica limitation of movement

Rheumatoid arthritis

Osteo arthritis

Shoulders

In which joints

Other

General symptoms

Fainting

Dizziness

Loss of sleep

Fatigue

Anxiety

Depression

Sudden weight loss/gain

Numbness

Tingling

Paralysis

Headaches(tension)

Migraines

Allergies

Infections

Hepatitis

Tuberculosis

HIV

Herpes

Cold

Flu

Athlete's Foot

Warts

Other

Digestive

Poor appetite

Belching / gas

Constipation

Diarrhea

Nausea

Ulcer

Vomiting

Skin

Rashes

Itching

Bruise easily

Dryness

Boils

Other

Cardiovascular

High blood pressure

Low blood pressure

Coronary heart disease

Heart attack

Phlebitis

Stroke / CVA

Pacemaker

Varicose veins

Swelling of the ankles

Poor circulation

Eye, Ear, Nose, Throat

Allergies

Frequent colds

Glasses or contacts

Hearing aid

Hearing loss

Sinus infection

Swollen glands

Hypersensitivity reactions

PLEASE INDICATE ALL CONDITIONS EXPERIENCING

Reproductive

Pregnant Due date

Painful menstruation

Heavy flow

Irregular cycle

Swollen breasts

Menopausal

Pre-menopausal

Post-menopausal

Regular eating habits

Yes

Do you take vitamins

Yes

Energy levels High

Average

Low

Consent & Agreement

I consent to receive massage and/or physiotherapy treatment and accept responsibility for any charges incurred. I understand that all information provided is confidential and will not be released without my written consent. I agree to give 24 hours’ notice for cancellations or I may be billed for the missed appointment.

Signature*

Today's Date*

+1 416 292 4445
Heading 5200 Finch Ave E, Suite 205 Scarborough, ON, M1S 4Z4
myoflexphysiotherapy@gmail.com

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