The Cranial Therapy Centre
Client Health History
The information request below will assist us in treating you safely. Feel free to ask any questions about the
information being requested. Please note that all information provided below will be kept confidentially
unless allowed or required by law. Your written permission will be required to release any information.
Date: ________________________________________ What is the reason you are seeking treatment? Please
include the location of any tissue or joint discomfort.
Patient name: __________________________________
_______________________________________________
Parent/Guardian name:____________________________
(if applicable) _______________________________________________
Address: _______________________________________ Are you currently receiving treatment from another
health care professional? q Yes q No
_______________________________________________
If yes, for what? ________________________________
Tel: Home ________________________________
Current
Business ________________________________ Medications and/or remedies: ___________________
Cell ________________________________ _______________________________________________
Email: ________________________________________ Conditions being treated: _______________________
Receive occasional emails? Yes q No q
_______________________________________________
How would you like your appointment
reminder? Phone:q Email: q What other treatments have you received? _______
Occupation: ____________________________________
_______________________________________________
Birth date: _____________________________________
Have you ever received massage therapy before?
Did a health care practitioner refer you? q Yes q No
q Yes q No
Past
If yes, please provide their name and address: Injuries (nature and dates): ______________________
_______________________________________________ _______________________________________________
Primary Care Physician: _________________________ Surgery (nature and dates): _____________________
Address: ___________________________________ _______________________________________________
Telephone: _________________________________
Overall, how is your general health? _____________ PLEASE COMPLETE THE FORM ON THE OTHER SIDE
_______________________________________________
Please cancel at least 24 hours in advance to avoid being charged for missed appointments.
OFFICE USE ONLY
Annual update _________________ ___________________________ ___________________________ ___________________________
_______________________________ ___________________________ Verbal consent received ___________________________
Client Health History continued
Please indicate conditions presently causing problems, as well as conditions which were a problem in the past.
BABIES & CHILDREN Present Past HEAD/NECK Present Past
Birth trauma.............................................q...............m Headaches ................................................q...............m
Feeding problems ....................................q...............m Migraines .................................................q...............m
Colic ..........................................................q...............m Jaw problems (pain/clicking/locking)......q...............m
Restlessness/sleep problems ....................q...............m Whiplash ..................................................q...............m
Recurrent ear infections .........................q...............m Vision problems or loss ...........................q...............m
Developmental Delays ............................q...............m Ear problems or hearing loss ..................q...............m
Behavioural issues ...................................q...............m Ringing in the ears...................................q...............m
Hyperactivity/ADD/ADHD .......................q...............m Fainting ....................................................q...............m
Learning Disabilities ................................q...............m Dizziness ..................................................q...............m
Eye motor problems ................................q...............m Sinus problems ........................................q...............m
PDD/autism ..............................................q...............m Facial pain.................................................q...............m
Closed head injury ...................................q...............m
RESPIRATORY Present Past Other neurological conditions ...............q...............m
Chronic cough..........................................q...............m
Shortness of breath .................................q...............m OTHER CONDITIONS Present Past
Bronchitis .................................................q...............m Epilepsy/seizures ......................................q...............m
Asthma .....................................................q...............m Diabetes ...................................................q...............m
Emphysema ..............................................q...............m Cancer: where ..........................................q...............m
Arthritis: family history............................q...............m
CARDIOVASCULAR Present Past Susceptible to colds/infections ...............q...............m
High blood pressure ................................q...............m High stress levels .....................................q...............m
Low blood pressure .................................q...............m Insomnia ..................................................q...............m
Chronic congestive heart failure ............q...............m Fatigue .....................................................q...............m
Heart attack .............................................q...............m Nervousness .............................................q...............m
Heart disease ...........................................q...............m Numbness/tingling/loss of sensation ......q...............m
Phlebitis/varicose veins ............................q...............m
Stroke/CVA ...............................................q...............m EVERYONE
Cardiovascular aneurysm ........................q...............m
Pacemaker/other device ..........................q...............m Is there any other information your therapist should know?
Coldness in extremities ...........................q...............m
_____________________________________________
DIGESTIVE CONDITIONS Present Past
_____________________________________________
Please describe: .......................................q...............m
_____________________________________________ Presence of internal pins, artificial joints, or special equipment _
INFECTIONS Present Past _____________________________________________
Skin conditions/infections .......................q...............m Known allergies or hypersensitive reactions?
Herpes ......................................................q...............m
HIV ...........................................................q...............m
_____________________________________________
TB ...........................................................q...............m
Hepatitis ...................................................q...............m
Other diagnosed diseases or medical conditions?
WOMEN Present Past
_____________________________________________
Gynecological conditions ........................q...............m
Pregnant, due ...............................................................
Therapist Use Only ______________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________