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Newmarket: (905) 953-8688 | Barrie: (705) 719-6888
MAKE AN APPOINTMENT
FORMS
Newmarket: (905) 953-8688 | Barrie: (705) 719-6888
MAKE AN APPOINTMENT
FORMS
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RMT Massage Treatment
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Massage Therapy Health History and Entrance Form
Massage Therapy Health History and Entrance Form
A complete health history helps us ensure it is safe to provide you with a massage treatment; please let us know if your status changes so we can update your form. All information given to us is confidential.
Your Name
(Required)
First
Last
Email
(Required)
We collect your email address to send you appointment reminders. Your email address will never be shared with a third party.
Home Phone
Cell Phone
(Required)
Work Phone
Address
(Required)
Street Address
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
Date of Birth
(Required)
MM slash DD slash YYYY
Age
Occupation
How did you hear about us?
Do you have insurance coverage for massage?
(Required)
Yes
No
Do you need the doctor's note for the massage treatment?
(Required)
Yes
No
Doctor’s Name
(Required)
Phone
(Required)
Date of the doctor's note issued
(Required)
MM slash DD slash YYYY
Doctor's Address
Street Address
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
Were you referred by another health care practitioner?
Yes
No
If yes, who
Have you had a professional massage before?
Yes
No
If yes, approximate date of last therapeutic massage
MM slash DD slash YYYY
Do you see other healthcare practitioners?
Chiro
Physio
Naturopath
Osteopath
Acupuncture
Other
Current Medications and Conditions Treating
Previous Major Illnesses/Operations (include dates)
Date
MM slash DD slash YYYY
Allergies/Hypersensitivities
Major Accidents (include dates)
Date
MM slash DD slash YYYY
What type of massage are you seeking?
(Required)
Relaxation
Therapeutic / Deep Tissue
What is your primary complaint?
What pressure do you prefer?
(Required)
Light
Medium
Deep
Please check all that apply to you
Respiratory
Chronic cough
Bronchitis
Asthma
Shortness of breath
Emphysema
Family history any of the above
Muscle and Joint
Jaw
Neck
Shoulders
Hands
Upper back
Mid back
Low back
Hips
Knees
Feet
Cardiovascular
High blood pressure
Low blood pressure
Heart attack/disease
Congestive heart failure
Stroke/aneurysm
Pacemaker
Varicose veins/phlebitis
Family history any of above
Infections
Hepatitis
Tuberculosis
HIV/AIDS
Herpes
Skin conditions
Skin conditions, what?
EENT
Vision loss/problems
Dental problems
Hearing loss/ear problems
Hearing aid
Sinus problems
Allergies/hypersensitivity to type of reaction
Allergies/hypersensitivity to type of reaction
Reproductive
Prostate problems
Pregnant, due
Gynaecological conditions
Due Date
MM slash DD slash YYYY
Gynaecological conditions
Gastrointestinal
Poor appetite
Distress from greasy foods
Excessive hunger/thirst
Belching or gas
Nausea
Vomiting
Burning in stomach
Pain over stomach
Constipation/diarrhea
Colon trouble
Liver trouble/hepatitis
Gall bladder
Ulcers
Colitis
Hemorrhoids
Hypoglycemia
Hiatal hernia
Metallic taste
Other
Arthritis OA/RA
Headaches/migraines
Loss of sensation/numbness/tingling
Diabetes
Cancer
Epilepsy
Haemophilia
Neuromuscular conditions
Osteoporosis
Mental illness
Family history of any of above
Artificial implants / pins / plates
Diabetes, onset
Cancer, where
Artificial implants / pins / plates; where
Lifestyle (check all that apply)
Yes
No
Mostly
Regular exercise
Drink plenty of water
8 hours of sleep nightly
Good eating habits
What is your general health?
Good
Moderate
Weak
Please read and sign:
(Required)
I agree to the policy.
• I attest that the information I have provided is true and complete to the best of my knowledge.
• I understand the information I have provided on this form is confidential and will not be released without my written consent.
• I understand that the Acupuncturist can end treatment at anytime due to inappropriate behaviour.
• I consent to a health assessment/reassessments and acupuncture treatment at Vitality Massage and Spa.
• I authorize Vitality Massage and Spa to contact my doctor or other health care professional listed above if required for treatment purposes.
• I understand that all sessions include a pre-health assessment and change time.
• I understand 24 hours notice is required to reschedule all future appointments, or full charges will apply.
I consent to receive updates on your services, products, promotions and rewards through
(Required)
SMS
Email
Select All
Signature
(Required)
Please sign using your finger or a mouse.
Date
(Required)
MM slash DD slash YYYY
Date updated
MM slash DD slash YYYY
Client initial
Date updated
MM slash DD slash YYYY
Client initial
Home
About
Services
RMT Massage Treatment
Facial Treatment
Acupuncture Treatment
Esthetic Body Services
Intense Pulse Light Therapy (IPL)
Body Contouring Treatment
Microneedling / Microdermabrasion
Packages
Other Services
Promotions
Membership
Gift Cards
Contact
