Patient Intake Form

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?

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?

If other, please specify:

Step 2

Please check any of the following if they apply to you:

General

If other, please specify:

Muscle / Joint / Bone

If you checked yes to arthritis, please specify location(s):

If other, or Arthritis, please specify:

Skin

If other, please specify:

Cardiovascular

If other, or Edema, please specify:

Women

If pregnant, please specify how many weeks:

If you checked breast conditions, please specify:

Respiratory

If other, please specify:

Genitourinary

Bladder infection
Incontinence
Kidney disorder

If you checked kidney disorder, please specify:

Nervous System

If other, please specify:

Systemic Disorders

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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