New Patient Questionnaire Kim McMahon RMT Collingwood, Barrie, Wasaga Beach, Stayner, Toronto Registered Massage Therapy

New Patient Questionnaire
All information will be kept strictly confidential.

Name *

Gender *

Date of Birth *

Address *

Phone Number *

Email Address *

Occupation *

Whom may we contact in case of emergency? Name & Phone Number *

Name & Phone Number of Medical Doctor (if you have one)

Briefly Describe Your Medical History *

Do you currently take any medications? *

Yes

No

If you answered yes to the question above please list what you are taking.

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

Yes

No

Do you feel pain in your chest when you do physical activity? *

Yes

No

Do you lose balance because of dizziness or do you ever lose consciousness? *

Yes

No

Do you have a bone or joint problem that could be made worse by a change in your physical activity? *

Yes

No

Have you ever tested HIV positive or been diagnosed with cancer? *

Yes

No

Are you 18 years of age or older? (You may submit this form but will be required to supply the signature of a parent or guardian on your first visit.) *

Yes

No

Message

MORE THAN JUST RELAXATION!

Kimberly McMahon RMT
MASSAGE THERAPY
Collingwood ON

Serving Patients Since 2011