South City
Massage Th
erapy
Physiotherapy
Pre
-
Exa
minati
on Quest
ionnaire
Name:
Date of Birth:
A
ddress:
Tel: (Home):
City:
Postal Code:
Tel: (Work):
E
-
mail:
Doctor:
THIS BOX FOR MVA PATIENTS ONLY!
A
uto Insura
nce Company
Information
Company Name:
Contact Pe
rson:
Branch Location:
Contact Tel:
Policy Holder Name:
Policy #:
A
ccident Date:
Claim #:
Extended Health Care Provider (if you have coverage)
The information requested below will assist us in treating y
ou safel
y
and effectively.
A
ll information pro
vided will be kept confidential unless disclosure is required by
law.
1.
Hav
e you received massage therapy before?
YES
NO
2.
How
is your general health?
3.
Has there been a
medical diagnosis?
YES
NO
If yes, who made the d
iagnosis?
When?
W
hat w
as the diagnosis?
4.
What medications are y
ou currently taking, and for what?
5.
Hav
e you ever had surgery or been hospitalized?
YES
NO
If Yes;
Date (approx.)
Nature of Surgery or Hospitalization
6.
Please Indicate i
f you are experiencing or hav
e experienced:
Cardiovascular:
Respira
tory:
High or Low Blood Pressure
Yes
No
Chronic Cough
Yes
No
Chronic Congestive Heart Failure
Yes
No
Shortness of Breath
Yes
No
Heart Attack
Yes
No
Bronch
itis
Yes
No
Phlebitis / Varicose Veins
Yes
No
Asthma
Yes
No
Stroke / CVA
Yes
No
Emphysema
Yes
No
Pacemaker or Similar Device
Yes
No
Other
Yes
No
Do you h
ave a family history
of any of the above? YES NO If Yes, which;