True Rehab Massage
Iovanca Stratan
(647) 893-7897
201 Consumers Road Suite 300A
M2J 4G8, Toronto, ON
Date of first visit:
Name:
Address:
Contact Number(s):
E-mail address:
DOB:
Age:
Marital Status:
Number of Children:
Age of children:
Occupation:
Dominant hand:
Chief Complaints
List in order of most important to least important and pain or dysfunction you feel is present in your body:
Date of dysfunction
1.
2.
3.
Have you seen a general practitioner or specialist for any of these problems?
Was there any treatment or diagnosis given?
Has the condition changed with treatment?
General Health:
Current Weight______ Height_______
Have you recently had any rapid weight gain or loss?
General energy level (scale of 1-10, 10 being optimal)
Average hours of sleep per night:
Do you wake up feeling refreshed?
Do you have difficulty falling asleep?
Do you have insomnia?
Do you suffer from Depression or Anxiety?
Do you feel extreme stress or pressure (general life, work) from day to day?
Do you wake up at night to go to the bathroom?
Number of times you wake up during an average night:
Can you fall back asleep easily?
Do you smoke presently?
Have you ever smoked? If yes, how long have you smoked?
Do you drink alcohol?
How often?
Do you drink coffee?
How much per day?
Do you drink soda?
How much per day?
How much water do you drink per day?
Are you a vegetarian?
Do you eat animal proteins?
How long?
How many meals do you eat per day on average?
Do you exercise regularly?
Types of exercise:
Have you ever seen a nutritionist?
Do you take any vitamin or supplemental products?
Have you been diagnosed with cancer?
Have you ever had any surgeries?
Bone
Tumor
Dental
Cartilage
Tendon
Organ
Implants
Transplants
Pacemakers
Joint replacements
Have you ever been hospitalized?
Type:
Cosmetic
Eye
Stints
How long?
Did you have any:
car accidents?
broken bones?
sprains or dislocations?
Have you had excessive hair loss?
Do you have any Large Scars?
Do you experience:
sudden tiredness/weakness?
fever/chills?
Time of day:
Do you sweat easily or excessively for unknown reasons?
Muscular
Ear
Shunts
Musculo-skeletal System:
Please check any areas that apply
_______Low Back pain
_______Difficulty walking
_______Mid-back pain
_______Broken bones
_______Neck pain
_______Torn muscles
_______Arm Problems
_______Muscle strains
_______Leg Problems
_______Ligament sprains
_______Joint pain or dysfunction
_______Cartilage dysfunction or tears
_______Muscular pain or dysfunction
_______Constant joint stiffness or ache
_______Arthritis
Nervous system
_______Numbness/tingling
_______Dizziness or Vertigo
_______Fainting
_______Frequent Headaches or Migraines
_______Frequent Muscle Twitching, ticks or spasms
_______Loss of coordination
_______Loss of balance
Nose and Sinuses
_______Nose Pain
_______Frequent nose bleeds
_______Difficulty breathing through nose
_______Hay fever
Mouth, Throat, Neck
_______Frequent sore throats
_______Gum problems
_______Grinding of teeth, TMJ, Clicking Jaw
Respiratory System
_______Asthma
_______Chronic/frequent coughing
_______Allergies
_______Frequent sinus infections
_______Nose surgery or reconstruction
_______Dental crowns, bridges, mouth work
_______Gland swelling
_______ Braces (current or history)
_______Pain on breathing
_______Frequent shortness of breath
Cardiovascular System and Peripheral Vascular System
_______High blood pressure
_______Irregular heart beat
_______Heart murmurs
_______Varicose veins
_______Heart palpitations
Gastrointestinal System
_______Frequent Constipation
_______Frequent diarrhea
_______Abdominal pain
_______Colitis, Crohns Disease, or Ulcers
Reproductive System
_____Prostate issues or enlargements
_____Fibroids, cysts, or endometriosis
_____Frequent cramping
_____Heavy flow during period
_____Menopause or pre-menopausal symptoms
_______Frequent Nausea/vomiting
_______Frequent heartburn
_______Frequent indigestion or gas
_______Frequent cramps
______C-section
______Prolapse
______Irregular cycle
______Currently pregnant (list week if checked)
If necessary, I allow my RMT to discuss with my health care provider the appropriateness of Massage
Therapy Treatments/MELT Method classes, for my general health and wellness and I understand that they
are not a replacement for medical treatment or medical diagnosis. I release my RMT from any kind of
claim or injury resulting from any act or omission during Massage Therapy Treatments/MELT Method
Classes.
I understand that I am responsible for full payment of my massage treatment if I cancel with less than 24
hours notice.
Please Date and Sign: _________________________________________________
Office Policies:
Consultations are by appointment only. Appointments are approximately 55 minutes. A special request is
made on behalf of chemically sensitive patients. Please come to the office as fragrant free as possible.
Many of the following items constitute a hazard to the sensitive clients:
shampoo/conditioner
hair spray/hair products
body oil/lotions
bath soaps
solvents, grease etc
deodorant
astringent/make-up
perfume/cologne starch
smoking
laundry detergent (scented)
fabric softener
after-shave cream
new clothing
Please fill out all forms as fully, accurately as possible. Small details are just as important as major issues in
assessing the body systems. Mental, emotional and social aspects of your life all play a role in your overall
health. Please feel free to mention any stress that you are experiencing prior to treatment or during.
All information is completely confidential. Thank you.
Fee Schedules and office hours:
Initial Assessments:
Continuing Sessions:
$______95_____ (75 minutes)
$______95_____ (60 minutes)
Cancellation Policy:
Please give a minimum of 24 hours notice if you are unable to keep your appointment. Otherwise you will
be charged for this time as it has been specifically reserved for you.
Payment:
This is due at the end of each session in full.
Patient Information:
Please do not eat any food if possible two hours prior to your visit. Please do not ingest coffee or tea the
day of your appointment. Life-sustaining medications and remedies may be taken. Drink at least 8oz. of
water prior to session as well as stay very hydrated the day after sessions. Try to abstain from heavy
physical exertion (aerobics, running, working out) for at least six hours before or after treatments. It is best
not to wear a watch, belts or jewelry for sessions, as I will ask you to take off any metal during sessions.
