Valley Massage Therapy Clinic-

Patient Medical History Form

Please complete this form to the best of your ability. Please print

Name: ______D.O.B.: (dd/mm/yy): ____/____/____

Gender: Male___ Female___

Address: ______Town: ______Postal Code: ______Telephone (h)_____-______-______(c)_____-_____ -______(w)_____-______- ______

Occupation: ______email(optional): ______

Private Medical Plan (policy #, ID#):______

IF MOTOR VEHICLE ACCIDENT:Agent,Phone Number, and Claim Number ______

Doctor: ______Town: Telephone: _____-_____ - ______

Chiropractor/Physiotherapist: ______

Company: ______Telephone: _____-_____-______

How did you hear of us: ______

Current Health History:

Medications (even Tylenol)

 Reason:

 Reason:

 Reason:

Relieving Factors: HeatIceExercise

Sleeping Patterns: ______

Do you have Pain at night? YES OR NO If yes, please describe:

______

Exercise Regularly?YES or NO If yes, please describe type and frequency: ______

Do you drink alcohol or smoke? : YES or NO

Other Modalities tried (Physio/Chiropractor/Osteopath/etc…): ______

Surgeries (with dates and treatments): ______

Plates/Pins/Screws/Pace Maker: YES or NO

Previous injuries and treatments (i.3. MVA, Strains, Sprains, Fractures, etc…): ______

Medical History:

Cardiovascular: / Skin: /  Dislocations
 Hemophilia /  Acne /  Broken Bones
 Hypertension /  Athlete's Foot /  Jaw Pain/ TMJ
 Bruise Easily /  Scoliosis
 Myocardial Infraction /  Sensitive Skin /  Bone or Joint Disease
 CVA (Strokes) /  Rashes/Eruptions /  Swelling
 Dizziness /  Sprains/Strains
 Poor Circulation / Respiratory: /  Tendinitis
 Phlebitis /  Asthma /  Bursitis
 Varicose Veins /  Emphysema /  Spasms/ Cramps
 Chest Pains /  Bronchitis /  Neck/ Head Pain
 Shortness of Breath /  Back/ Hip Pain
Digestive /  Sinus Problems /  Leg/ Knee/ Foot pain
 Indigestion /  Chronic Cough /  Shoulder/ Arm Pain
 Constipation /  Allergies: ______/  Wrist/ Hand Pain
 Diarrhea / ______/  Chest/ Abdominal Pain
 Diverticulitis
 IBS / Reproductive: / Other:
 Chron’s Disease /  Pregnancy /  Herpes/ Shingles
 Colitis /  PMS /  Hepatitis
 Liver/Gallbladder problems /  Menopause /  HIV/ AIDS
 Kidney Disease /  Pelvic Inflammatory /  TB
Disease /  Cancer(where)______
Neurological: /  Prostate Problems /  Diabetes
epilepsy /  Endometriosis /  Hearing/ Vision loss
 Multiple Sclerosis /  Hysterectomy /  Insomnia
 Cerebral Palsy /  Fainting
 Muscular Dystrophy / Muscle/Joints: /  Loss of Appetite
 Parkinson’s /  Joint Stiffness /  Depression
 Spinal Cord Injury /  Arthritis/OA/RA /  Stress
 Paralysis /  Osteoporosis /  Fibromyalgia
 Numbness/Tingling /  Limited Movement /  Chronic Fatigue Syndrome
 Neuritis/Neuralgia /  Excessive Movement /  Post/ Polio Syndrome
 Migraines

To the Clients of Reflexology, you need to know that:

1.The Reflexologist is not a doctor.

2.She/he does not practice medicine.

3.She/he does not diagnose or treat for a specific illness.

4.She/he does not prescribe or adjust medication.

5.Reflexology is not a substitute for medical treatment, but is a complement to most types of therapy.

What is Reflexology?

Reflexologists believe the entire body is mirrored on the feet and hands. Foot and hand reflexology is a scientific art based on the premise that there are zones and reflex areas in the feet and hands which correspond to all body parts. The physical act of applying specific pressures using thumb, finger, and hand techniques, results in stress reduction, which causes physiological changes in the body. A primary benefit of reflexology is relation. Relaxation through reflexology may help the body to balance any kind of stress it is experiencing.

What does Reflexology do?

1.Reflexology promotes balance and normalization of the body naturally.

2.Reflexology reduces stress and brings about relaxation; and

3.Reflexology stimulates circulation and the delivery of oxygen and nutrients of the cells.

Contract for Services

By signing this form, I give my consent to a Reflexology. I understand I may discontinue a session or sessions at any time. I further understand that I must disclose at this time if I am a government official or representing news media. If I have been diagnosed by a licensed health professional as having any disease, injury, or other physical or mental condition, I understand that reflexology sessions are not a substitute for any treatment or therapy previously ordered, prescribed, or recommended by that health professional.

Cancellation Policy:

Please provide 24 hours notice for any changes to your appointment time. For missed appointments or late cancellations the full fee of the scheduled treatment will be charged to you personally (insurance companies will not pay for missed appointments).

I understand that all the information contained in this form is confidential, and will only be discussed with a third party when necessary to help aid in the management of my case. I will authorize the release of my information either verbally or in writing when a lawyer, Insurance company or another professional requests for it in writing. Consent for release of this information to my family physician or referring practitioner is assumed by signing this form.

I understand that I have the right to withdraw my consent for the release of this information at any time with written notification to Valley Massage Therapy Clinic.

Signature: ______Date: ______

Print Name: ______

REFLEXOLOGY IS NOT A SUBSTITUTE FOR MEDICAL CARE.