New Client/Patient Information Form Step 1 of 3 33% Personal InformationName* First Last Date Of Birth Date Format: MM slash DD slash YYYY Email* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country OccupationHow did you hear about our RMT services? Friend Google Search RMT Find Other Name of Family Dr.Family Dr. Phone Number Daily InteractionsComputer work (hours/day)Smoking Yes No Occasionally Quit or Quitting Drinking Yes No Occasionally Quit or Quitting Special DietExample: Coeliac Disease, Gallbladder Removal, IBS etc. HEALTH HISTORYPrimary areas of concern(ie shoulders/neck/low back)Respiratory*Please indicate conditions you are experiencing, or have experienced Chronic cough Shortness of breath Bronchitis Asthma TB Emphysema Allergies COPD Does Not Apply Cardiovascular*Please indicate conditions you are experiencing, or have experienced Heart Attack Low Blood Pressure High Blood Pressure Pacemaker Poor Circulation Heart Disease High Cholesterol Phelbitis Does Not Apply Skin*Please indicate conditions you are experiencing, or have experienced Sensitive Skin Loss of sensation Rashes / Uticaria Allergies Bruise Easily Skin conditions Varicose Veins Eczema/Psoriasis Body Eczema/Psoriasis Scalp Skin Cancer Cold Sore Warts Athletes Foot Herpes Does Not Apply Digestion/Uro-Genital*Please indicate conditions you are experiencing, or have experienced Constipation IBS Urinary Tract Infections Heartburn Kidney Issues Does Not Apply Female Health*Please indicate conditions you are experiencing, or have experienced Pregnant PMS Menopause Hysterectomy Does Not Apply Muscles/Joints*Please indicate conditions you are experiencing, or have experienced Neck Back Leg Arm Shoulder Knee Hands Feet Arthritis Fibromyalgia Scoliosis Multiple Myalgia ALS MS Does Not Apply Other*Please indicate conditions you are experiencing, or have experienced Anemia Communicable Disease Diabetes Insomnia Epilepsy Arteriosclerosis Stroke Cancer Thyroid Imbalance Organs Removed Organ Problems Chronic Fatigue Metal Implants (pins, rods) Claustrophobia Does Not Apply Psychological/Psychiatric/Counseling HistoryPlease list any sprains/strains/fractures/dislocations (past or current)Current MedicationsPlease list any medications you presently use or have within the past yearPresent Involvement in other Health CareUndergoing any active procedures or treatments.Other Health ConcernsPlease list any other health issues that may not be indicated above.Please list any serious illnesses (past or current)Please list any surgeries you’ve had, including datesPlease list any major accidents (auto/falls, etc.)Please let your therapist know if you have any special requests or goals relating to your sessions (ie. upcoming competitions, races etc.)Special Notes:Please let your therapist know if you have any special requests or goals relating to your sessions (ie. upcoming competitions, races etc.)Agreement*By digitally signing this document I agree to the following: Hereby grant the Registered Massage Therapist permission to initiate the assessment and rehabilitation protocols necessary for the treatment of my injury or injuries. Give permission to Registered Massage Therapist to obtain any form of medical documentation relating to my injury and or condition, such as, (but not limited to) x-ray reports, MRI reports and CT scan reports. I understand and agree to the terms above.
