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Bowen By The Bay

Natural healing and relaxation therapy, IT WORKS WONDERS!

Client Forms

Health History Form

DATE ___________________________________________________________

NAME__________________________________________________________________________

ADDRESS ________________________________________________________________________________

 CITY/PROVINCE/STATE__________________________________________________________


ZIP CODE________________________________________________________________________

 EMAIL_____________________________________________________________

HOME PHONE_____________________________________________________

BUSINESS PHONE_______________________________________________________________________________________ 

Can I call you at work? ______

Referred by: ________________________________________________________

Date of Birth ______________________________________________

Physicians Name and phone number_______________________________________________________________________________________
 
Emergency Contact: 

NAME __________________________________________________________

 PHONE NUMBER _________________________________________________

Primary complaint/reason for treatment: 

 ________________________________________________________________________________________________

Pain location:  _____________________________________________________________________

Intensity of pain on a scale of 1-10  ______________

 

What Medications are you currently taking?

__________________________________________________________________________________

__________________________________________________________________________________


List surgeries with dates: (Please include TMJ or oral surgery) ________________________________________________________________________________

_________________________________________________________________________________

________________________________________________________________________________                                                       


List previous injuries with dates:
______________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Are you pregnant or trying to conceive?
   _________________________________________________________________________________________________

Indicate your own birth history if known:  i.e. c section, forceps, breech birth, premature

_________________________________________________________________________________

Do you smoke? _______________ How much? ______________ How long? ______________ 

Do you wear orthotics? ______________________ How long for current pair _______________ 


Have you received any other form of body work in the past five days?  Please indicate type.

 _____________________________________________________________________________


Do you have any metal implants, internal pins, wires, artificial joints or special equipment? ________________________________________________________________________________

_________________________________________________________________________________

What is your daily consumption of water ____________     Tea ___________   Coffee_________

Soft drinks __________________     Alcoholic beverages _____________________


Please indicate conditions you are experiencing or have a history of with explanation:


o    Bronchitis/asthma/shortness of breath or chronic cough    _____________________________________________________

o    Poor circulation/bruise easily __________________________________________________________


o    Loss of sensation in hands or feet______________________________________________________________

o        Pregnant    Due date:   __________________________________________________________________

o        PMS, fibroids/difficult menstruation         ___________________________________________

o          Last menstrual period: _________________________________________

o        Liver/gallbladder/poor digestion _________________________________________________________________

o        Insomnia __________________________________________________________________

o        Hiatus hernia _______________________________________________________________

o        Constipation/diarrhea - please indicate number of BM’s per day or per week _______________________________________________________________

o        Numbness/tingling _____________________________________________________________ _____________________________________________________________

o        Diabetes   
        Date of Onset: ____________________________________________________

o          Allergies   (Anaphylaxis/skin irritation/food allergy) __________________________________________________________________
    
o          Hayfever  __________________________________________________________________

o        Epilepsy __________________________________________________________________

o        Cancer   __________________________________________________________________ __________________________________________________________________

o        Arthritis _________________________________________________________________ __________________________________________________________________

o    Vision problems__________________________________________________________

o    Ear infections/poor hearing/tinnitis_________________________________________________

o    Bladder/kidney _________________________________________________________________

o    Joint or soft tissue pain ____________________________________________________________________________________________________________________________________

o    High or low blood pressure __________________________________________________________

o    Heart attack __________________________________________________________________

o    Congestive heart failure, heart disease, stroke ____________________________________________________________________________________________________________________________________

o    Phlebitis _______________________________________________________________ 

o    Pacemaker   __________________________________________________________________

o    Headaches (frequency and triggers) ____________________________________________________________________________________________________________________________________

o    Hepatitis, TB _____________________________________________________________________

o        Skin rashes/infectious skin conditions __________________________________________________________________

o        Fibromyalgia ______________________________________________________________ __________________________________________________________________

o        Mononucleosis ___________________________________________________________ __________________________________________________________________

o        Back pain _________________________________________________________________ __________________________________________________________________

o        Varicose veins ____________________________________________________________ __________________________________________________________________

 

I, (print)__________________________________________ understand the treatment goals, risks and benefits as explained by the nurse and I give consent to treatment.  I have had an opportunity to ask questions about the treatment.  I understand that ____________ does not 


treat, prescribe or diagnose any illness, disease, or other physical or mental disorder and that any information concerning health status relayed to _____________ has also been given to my physician.  I also certify that no guarantee has been made as to the results that may be obtained.


I hereby give _________________ permission to collect personal information, including personal health information from me and from the facilities and persons listed and to release such information to the following facilities and/or persons for the purpose of providing services to me and for the purpose of information sharing in support of care planning and service provision.  These facilities/persons include your health care team i.e. physician, pharmacist, naturopath, RMT, chiropractor or other regulated health care provider. I understand I may request access to my personal information at any time and may revoke or amend this authorization in writing at any time.  Upon completion of my treatment program, any request for ____________________ to share/release client specific information acquired through the episode of care will require a specific informed consent from the client for release of specifically requested information.

 

Signature______________________________________________Date ______________________________

 

        

Associated Bodywork & Massage Professionals
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