Patient Intake Form

All new patients to the Public Intern Clinic must complete a patient intake form which assists us in becoming familiar with your health history and ensures that the massage therapy services provided are best suited for you. Patients can either complete a printed form when they arrive at the clinic for their appointment or complete the online form in advance.

If you choose to complete the online form, you must have already booked your appointment which can be done either online or by phone at 604-520-1830

Personal Information
Name*
First Last
Date of Treatment*
Time of Treatment*
Please book a time with us BEFORE completing this form.

: HH

MM
Date of Birth*
Are you?
- Male
- Female
Gender
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Occupation
Phone*
Alternative Phone
Email
Would you like to join our Valued Partners Program? You'll receive notice of new promotions and 50% off a future treatment. (Please provide email above)*
- YES
- NO
Would you like to join our Valued Partners Program? You will receive our monthly clinic promotions and updates, as well as valuable clinic coupons.”*
- YES
- NO
Step 1
1. Are you currently receiving treatment from any of the following healthcare practitioners?
- Chiropractor
- Massage Therapist
- Medical Doctor
- Physiotherapist
- Other
If other, please specify:
Are you over the age of 16?*
Please note: Massage therapy CANNOT be given if you are under 16 years old without the consent of a parent or legal guardian.
- YES
- NO
Are you presently involved in a WCB or ICBC litigation/claim involving an injury?*
Please note: Massage therapy CANNOT be given at WCCMT if you are on an ICBC/WCB claim.
- YES
- NO
Have you had a bad/negative reaction to heat or cold?
- YES
- NO
How did you hear about the WCCMT student clinic?
- Friend
- Student
- Co-worker
- Family member
- Website
- Advertising
- Other
If other, please specify:
Step 2
Please check any of the following if they apply to you:
General
- Allergies
- Depression/Anxiety
- Dizziness
- Fainting
- Headaches
- Loss of sleep
- Weight loss/gain
- Other
If other, please specify:
Muscle / Joint / Bone
If you checked yes to arthritis, please specify location(s):
- Arthritis
- Low back pain
- Mid back pain
- Muscle weakness
- Neck pain
- Osteoporosis
- Sore / achy
- Stiff / tight
- New Injury
- Other
If other, or Arthritis, please specify:
Skin
- Bruise easily
- Dry / Oily
- Eczema
- Hives / Rash
- Psoriasis
- Other
If other, please specify:
Cardiovascular
- Anemia
- Arteriosclerosis
- Cold feet
- Heart disease
- High/low blood pressure
- Pace maker
- Poor circulation
- Rapid/Irregular pulse
- Rheumatic fever
- Stroke
- Swelling of ankles
- Varicose veins
- Edema
- Other
If other, or Edema, please specify:
Women
- Menopause
- Pregnant
- Postnatal
- Breast conditions
- Other
If pregnant, please specify how many weeks:
If you checked breast conditions, please specify:
Respiratory
- Asthma
- Bronchitis
- Chest pain
- Chronic cough
- Difficulty breathing
- Emphysema
- Pneumonia
- Other
If other, please specify:
Genitourinary
- Bladder infection
- Incontinence
- Kidney disorder
If you checked kidney disorder, please specify:
Nervous System
- Numbness/Tingling
- Epilepsy
- Parkinson's
- Multiple Sclerosis
- Other
If other, please specify:
Systemic Disorders
- Cancer
- Diabetes (Type?)
- Fibromyalgia
- HIV/AIDS
- Osteoporosis
- Post Polio Syndrome
- Thyroid disease
- Other
Please specify if you checked yes to: cancer, diabetes and/or other:
Step 3
Please give a detailed description of the problem you are currently experiencing:
How long have you had this condition and is it getting better or worse?
When does it bother you the most? When you're at work, sleeping, other? Please specify:
What seemed to be the initial cause?
To what level are you currently satisfied with your?:
Please check the level which you feel most accurately describes you (i.e. low, moderate, or high).
Physical health & fitness:
- Low
- Moderate
- High
Mental and emotional happiness:
- Low
- Moderate
- High
Diet:
- Low
- Moderate
- High
Ability to relax:
- Low
- Moderate
- High
Exercise level:
- Low
- Moderate
- High
How is most of your day spent?
- Standing
- Sitting
- Other
If other, please specify:
When was your last physical exam?
If you can't remember the exact day and month, a rough estimate is fine.
Please describe your stress level:
Have you ever been?
Please check all those that apply.
- Hospitalized (surgeries, other)
- Suffered from depression/anxiety
- Had any broken bones
- Had any strains or sprains
- Used orthotics
- Had pins, plates, screws, rods, prosthesis, breast implants
If yes, please explain briefly:
Please list any medications you are currently taking and why:
Do you use alcohol, tobacco, and recreational drugs? If so, please describe below:
Is there anything else your student therapist should know?
Consent & Release
I acknowledge that the above information is accurate and true to the best of my knowledge. I understand that this is a teaching massage clinic and accordingly, a clinic instructor who is a Registered Massage Therapist may be present during any aspect of my treatment. I acknowledge and confirm that the benefits, risks, side effects and potential complications of treatment have been explained to me by my intern therapist. As such I agree to participate in an assessment and treatment program. My consent is voluntary for the entire course of treatment for my present condition, commencing on the date indicated below. I understand that I may ask questions at any time and that my consent may be withdrawn at any time. Liability Release Disclaimer: The West Coast College of Massage Therapy Inc., its employees, servants and agents (the “college”), do not accept liability for any claim as to the method or manner of treatment given, or any complaint related to supposed conditions arising from therapy. In good and valuable consideration, the undersigned does hereby release and forever discharge the College, its successors and assignees, from any other legal obligations and compensation of whatsoever kind and howsoever arising from or out of any treatment which will be provided to the undersigned. My signature provided below attests to my understanding and agreement to the above.*
- I Agree
- I Do NOT Agree
Patient Signature
Date*
Instructor Signature
Date*

Personal Information

Step 1

Step 2

Step 3

To what level are you currently satisfied with your?:

Consent & Release

Patient Signature

Instructor Signature

Accreditations

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