Massage Experts Ottawa Barrhaven | Health History Form

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Welcome to Massage Experts Ottawa Barrahven
Located at 1055 Greenbank Road @ Highbury Park Drive.
barrhaven@massageexperts.ca
613-424-4762

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All other fields are optional.

Personal Info

First Name

Last Name

Date of Birth (MM/DD/YYYY)

Gender

Occupation

Contact Info

Mobile Phone

Home Phone

Work Phone

Address

City

Country

Province / State

Postal / Zip Code

Emergency Contact

Emergency Phone

Relationship

Doctor

Doctor's Name

Doctor's Phone

Doctor's Address

Do you have a doctor's referral for your treatment?

YES

Do you currently see any other health professional?

Acupuncture

Chiropractor

Naturopathy

Osteopathy

Physiotherapy

Other

Medications

Medication

Injuries

Injury

Surgeries

Surgery

YOUR HEALTH PROFILE

Treatment Goals

Improve Symptoms

Increase Well-Being

Injury Rehabilitation

Pain Relief

Stress Relief

Improve Flexibility

Other

Treatment Preferences

Light Pressure Preferred

Medium Pressure Preferred

Deep Pressure Preferred

Light to No Talking Preferred

Light to Moderate Talking Acceptable

Light to No Music Volume

Moderate Music Volume

Increased Music Volume

Other

Area(s) of Complaint

What best describes what you are feeling / experiencing?

Energy Level

High

Low

Fatiqued

Allergies

Cardiovascular

Cardiovascular Conditions

High Blood Pressure

Low Blood Pressure

Heart Attack

Cardiac Arrhythmia

Pacemaker

Varicose Veins

Blood Clots

Phlebitis

Emotion / Memory

Anxiety Disorder

Mood Disorder

Schizophrenia

Stress

Substance Use Disorder

Alzheimer Disease

Respiratory

Asthma

Chronic Cough

Shortness of Breath

COPD

Cystic Fibrosis

Infectious Respiratory Conditions

Headaches

Chronic Daily Headache

Headaches

Migraines

Tension

Cluster

Sinus

Musculoskeletal

Neurological

Parkinsons

Sciatic Pain

Fibromyalgia

Carpal Tunnel

Stroke

Vertebral and Spinal Cord Injury

Herniated Disc

Chronic Pain Disorder

Other Neurological

Gastrointestinal

Crohn's Disease

Celiac Disease

Irritable Bowel Syndrome

Other Gastrointestinal

Immune

Rheumatoid Arthritis

Lupus

Leukemia

Cancer

Type of Cancer

Date of Diagnosis

Endocrine

Hyperthyroidism

Hypothyroidism

Diabetes

Pituitary and Growth Disorder

Other Endocrine

Skin

Blood

Hepatitis

Thrombosis/Embolism

High Cholesterol

Anemia

Bleeding Disorder

HIV/AIDS

Miscellaneous

Vision Problems or Loss

Hearing Problems or Loss

Mental Health Conditions

Surgical Pins or Wire

Insomnia

Other Medical Conditions

Other Diagnosed Diseases

Family History

Arthritis

Cardiovascular

Respiratory

Reproductive Health

Are you currently pregnant?

YES

Approximate Due Date:

Any pregnancy complications or health issues?

YES

If Yes, please explain:

If required to further treatment, may we have permission to contact your obstetrician or prenatal care provider?

YES

If Yes, please provide contact information if different from top of form.

Are you receiving any ongoing medical care for any conditions not listed above? (If yes, please explain)

Yes

SENSITIVE AREAS CONSENT

I am aware that as part of my professional massage therapy treatment or bodywork service, my practitioner may be required treat my buttocks, inner thigh, breast tissue or chest wall musculature to address my concerns. If I DO NOT wish to have any of those areas treated, I will advise my practitioner prior to treatment. If at any time I need to ask the practitioner to stop or modify the treatment, I can do so.

Yes

Based on your unique treatment needs, you may be asked to fill in a more detailed Sensitive Areas Consent Form for this or future Massage Therapy treatments or bodywork services, depending on what treatment plan may be required for you.

INSURANCE DIRECT BILLING (IF APPLICABLE):

Massage Experts offers insurance direct billing for therapeutic massage treatments to most major insurance companies. If you would like us to provide this for you, please fill in the following information. Please then provide your insurance card for verification at appointment time. If you do not have or require direct billing, please skip this section. For a list of all participating insurance providers, please visit the insurance section on our website, www.massageexperts.ca.

Would you like to request insurance direct billing capabilities for your treatment(s)?

Yes

Insurance Company Name:

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Insured Member's First and Last Name:

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Your Relationship to Insured Member:

Policy Holder

Spouse

Child

Other

Insurance Policy or Group Number:

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Insurance Policy ID Number:

Characters: 0/255

Please note that different insurance carriers have different operational policies, and you may be required to fill out additional paperwork for your direct billing request once onsite at Massage Experts.

HOW DID YOU HEAR ABOUT MASSAGE EXPERTS?

MARKETING & COMMUNICATION CONSENT:

I agree to receive promotional emails from Massage Experts (generally 1-2 per month). I know that my decision can be altered and that I can unsubscribe at any time. I know that my information will never be sold to a third-party.

Yes, I agree to receiving promotional emails

No, I do not wish to receive promotional emails

Your personal information is protected and completely confidential. In accordance with the local massage asssociation(s), all Massage Therapists and treatment providers require a health history information to provide clients with safe and effective treatments. Health history forms will be updated annually to ensure your records are accurate and complete. You will be asked to provide written authorization for the release of any information in your file. Treatment records will be kept for a period of 10 years after your last treatment date or, if under 18 at the time of treatment, records will be kept for 10 years after your 18th birthday. If you need to access, update, or correct your records, please contact us via email with the request.

Review & Agree

* I agree to the Massage Experts 24hr cancellation policy

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* I agree to the insurance Electronic Transmission Authorization and Consent (if direct billing is applicable)

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