Sarah Ritchie, BA, RMT, Dipl.Ac., 1 The Root of Health, 1525 Cornwall Rd., Oakville, ON L6J 0B2 HEALTH HISTORY INTAKE FORM An Accurate Health History is important to ensure safe and effective treatment. Please fill out accordingly. Name: Today’s Date: Address: E-mail:
Tel (H): Tel (W): Tel (C): Occupation: Male Female Marital Status: Do you have children? Y N How many? Emergency Contact/Relation to you: Emerg. Tel: Referred by: Date of Birth: Age: Physician’s Name & Location: Physician’s Tel: Other Current Therapies & Details:
Are you pregnant? Due: Do you wish to receive our E-mail newsletter? Y N Have you had massage before? Y N This health history form is inclusive for acupuncture, however you Have you had acupuncture before? Y N will provide consent only for the services you wish.
Please identify your main health concern or Chief Complaint: Practitioner Use Only:
How long have you had this condition? How does it affect your daily activities: sleep, eating, work?
What seems to make it better or worse? Is there a medical diagnosis?
Practitioner Use Only:
Please identify your secondary and other health concerns with details:
Please check soft tissue/joint discomfort areas: Neck Upper Back Legs Low Back Shoulders Knees Mid Back Arms Other:
Family Health History (parents): Allergies/Asthma Thyroid Disease Rheumatic Heart Disease/ Epilepsy/ Fever/ Auto-immune Stroke Seizures Dis. Cancer: type? Kidney Disease Diabetes: type? Blood Pressure: Skin Problems High/Low Depression/ Alcoholism Other: List Age of Parents (if living): Father: Mother: Mental Condition Or Age (at death & cause of death): Father: Mother:
Your Personal Health History: (please check box, and then circle applicable condition) Allergies/Asthma/ Thyroid Disease: Rheumatic Heart Disease/ Stroke/ Phlebitis Emphysema hyper/ hypo? Fever/ Auto-immune CCHF Dis. Chronic Cough/ Epilepsy/ TB Vision problems/ Hearing Sarah Ritchie, BA, RMT, Dipl.Ac., 2 The Root of Health, 1525 Cornwall Rd., Oakville, ON L6J 0B2 HEALTH HISTORY INTAKE FORM An Accurate Health History is important to ensure safe and effective treatment. Please fill out accordingly. Shortness of Breath Seizures vision loss problems/ hearing loss Practitioner Use Only/Annual Updates: Year: Cancer: type? Kidney Disease Diabetes: type? Blood Pressure: Skin Problems High/Low Depression/ Liver Disease/ Digestive Anemia Mental Condition Hepatitis- type? Diseases? CFS/Fibromyalgia Osteoporosis Arthritis: Osteo, Eating Disorders Alcoholism/Drug Cold Sores/ Rheumatoid? Dependency Herpes- type? Lung Disorders; Goiter Gout Venereal Other: Emphysema, Pleurisy, Disease Pneumonia Central Nervous System/Auto-immune Disorders: MS CP Parkinson’s ALS Guillain-Barre Syndrome HIV/AIDS Other: Malaria Surgeries: Date: Trauma/Injuries: Date: Chicken Pox Measles Scarlet Fever Other:
Medications: Practitioner Use Only: Prescribed/Over-the Counter/Vitamins/Herbs & Purpose for taking them
Work and Lifestyle Do you enjoy work? Y/N Why or why not? Daily/weekly physical exercise? Spiritual practice? Interests/hobbies (incl. TV, computer, reading) Alcohol Cigarettes Drugs
Neuro/Emotional Poor Memory Difficult to focus Easily Irritated Anger Anxiety
Depression Worrying Fears Fatigue Mood Swings
Sighing Easily Emotional Eating Low Motivation Feel ‘Stuck’ Susceptible to Stress Have you ever been treated for emotional problems?
Energy Levels/Fatigue How would you describe your energy levels? Low Average High If your energy is low, please describe:
Do you have anything of Note that would affect the use of either Massage Therapy, Heating Units or Electro-Acupuncture? Sarah Ritchie, BA, RMT, Dipl.Ac., 3 The Root of Health, 1525 Cornwall Rd., Oakville, ON L6J 0B2 HEALTH HISTORY INTAKE FORM An Accurate Health History is important to ensure safe and effective treatment. Please fill out accordingly. Internal pins/ Wires/ Artificial joints/ Pacemaker Other:
Your Diet (This applies for Acupuncture & Shiatsu treatments) low appetite fruit low protein sugar/sweetners spicy foods # glasses water/day: juices/pop intake high appetite caffeine high protein salty foods fried foods intake Average Daily Menu Morning Snack Lunch Snack Evening Snack
For safety reasons do you have any of the following? Epilepsy, Heart Palpitations, Bleeding Disorders? Are you pregnant, or trying to get pregnant? If yes, explain:
Consent for Treatment I (print name)______consent to be treated for the chief complaint(s) that I have described to my therapist, and any future complaints that I provide verbal consent to be treated for. I agree that, for the purpose of Massage Therapy and/or Acupuncture, the following areas may be addressed as is necessary during the course of my future treatments: □ Entire body OR: □ Back (□ Upper □ Lower) □ Shoulders (□ R □ L) □ Neck □ Arm (□ R □ L) □ Hand (□ R □ L) □ Leg (□ R □ L) □ Feet (□ R □ L) □ Head/Scalp □ Face
Sensitive Areas Consent: □ All of the Sensitive Areas □ Gluteals (buttocks) □ R □ L □ Abdominals □ Chest (Pectoral muscles) □ Adductors (inner thigh) □ Pubic Bone (for locating Acu pts) □ Coccyx (Tail Bone) □ Sacrum □ Sternum (breastbone) □ Breast I consent to treatment using the above areas as is necessary for my care. I agree to treatment using the modalities encompassed within, or complimentary to Swedish Massage (with my consent, this may include: Deep tissue/Sports Massage, Craniosacral Therapy, Fascial Work, Hot Stone Massage, Shiatsu Massage, Tui-na Massage, Cupping, Moxibustion and Reiki). I may also provide written consent below to treatment with Acupuncture. I realize that I may stop or modify my treatment at any time. (You will be given an opportunity to provide consent only for the treatment that you are requesting, and you may update or modify this consent at a later date).
I understand that the above therapies may assist in my healing; increasing muscle length, decreasing muscle tension and relieving pain, increasing the circulation of blood, and lymphatic flow, improving range of motion, and creating relaxation and a sense of well-being. Where applicable the above treatments may also assist in supporting internal health concerns.
Though not common, I am aware that possible side-effects of the above treatment includes: dizziness/faintness, nausea, and fatigue. The risks of the above treatment may include muscle stiffness or soreness, aggravation of nerve referral symptoms, mild bruising, mild skin burns (applies to Moxabustion or Cupping) or hematomas (localized swelling from bursting a small blood vessel, applies only to acupuncture). Sarah Ritchie, BA, RMT, Dipl.Ac., 4 The Root of Health, 1525 Cornwall Rd., Oakville, ON L6J 0B2 HEALTH HISTORY INTAKE FORM An Accurate Health History is important to ensure safe and effective treatment. Please fill out accordingly. In the case of acupuncture treatment, the use of sterilized disposable needles (single use only) eliminates the risk of hepatitis B, hepatitis C and AIDS transmission.
All acupuncture points have a particular protocol, that is, a specific angle and depth that is allowed, and are measured against the size and structure of each individual’s anatomy, making it quite easy to be protected from any harm. In extremely rare cases the puncture of an internal organ has been reported in the literature. Equally rare is the report of a needle breaking. Both of these situations would require medical intervention. Proper training and serious precautions are always observed by a wise practitioner to avoid any of these complications. On the whole, acupuncture is really quite safe.
Acupuncture may be contraindicated for the following conditions: Heart Pacemaker (only for electro- acupuncture), Seizure type disorders, Hemophilia or other bleeding disorders, and Pregnancy (certain points are disallowed, due to their stimulatory nature). (A pregnant patient desiring acupuncture will be referred to a practitioner with specialized training in this area.)
Patients who are very hungry, drunken, or under the influence of recreational drugs may not be treated. Please eat 1 ½ - 2 hours prior to treatment.
The procedures of treatment have been explained to me fully by the therapist, including areas to be treated, modalities, benefits, risks and side-effects. I have been given an opportunity to have all of my questions answered in regards to the treatment. I understand that I may refuse or modify my treatment plan at any time. I also verify that all of the information given on this form is true and accurately reflects my past and present health status.
Therapist Name: Sarah Ritchie, BA, RMT, Dipl. Ac., Reiki Master
**Please sign this section in the presence of the therapist so that you may ask questions and confirm your verbal and written consent.**
In compliance with the “Consent to Treatment Act” (Bill 109), I provide full, voluntary and informed consent to treatment. I intend this consent to pertain to my entire course of treatment.
I consent to Treatment with Massage Therapy.
Client Signature: ______Date:
I consent to Treatment with Acupuncture Therapy.
Client Signature: ______Date:
Consent for Collection, Use & Disclosure of Personal Health Information Since 2004 the Ontario laws, PHIPA (the Personal Health Information Protection Act) and PIPEDA (the Personal Information Protection and Electronic Documents Act) have been governing how organizations collect, use and disclose personal information. This act is intended to protect you and your personal information, and is required by Ontario Law.
Under PHIPA and PIPEDA laws (2004), Sarah Ritchie, as your health custodian at the Root of Health, agrees only to collection of your personal health information for the following purposes: Sarah Ritchie, BA, RMT, Dipl.Ac., 5 The Root of Health, 1525 Cornwall Rd., Oakville, ON L6J 0B2 HEALTH HISTORY INTAKE FORM An Accurate Health History is important to ensure safe and effective treatment. Please fill out accordingly.
Collection of an accurate health history for the purposes of health care diagnosis & treatment Continued collection of updates in your health history during ongoing treatments Collection of appropriate medical professional and family contact information only for the purposes of medical consultation or emergencies Collection of your contact information only for the purposes of appointment reminders, or consultation with Sarah Ritchie in regards to your treatment Additional consent may be provided at your discretion in regards to receiving our monthly e-mail newsletter, or other mailings from the Root of Health Sarah Ritchie, as your health custodian, will ensure that your health information is protected and remains safe within your health file, and will not be disclosed to any other individual except for the purposes of consultation with another health professional for your treatment. In the case of such consultation, your name and contact information will not be given. Your health history information will not be disclosed for any other purpose without express written consent by you Should Sarah Ritchie, as your health custodian relocate her practice, you will be notified of this change, and your file will remain in her safe keeping You may receive a copy of your health history file at any time by providing a written request You have the right for your privacy to be respected, and can make complaints to the following: Information & Privacy Commissioner for Ontario, 2 Bloor St. East, Toronto. 416- 326-3333 You may withdraw this consent at any time This consent is required in order for you to receive treatment
I hereby authorize Sarah Ritchie, on behalf of the Root of Health, to collect, use, and disclose my personal health information for the purposes stated above
Signature: ______Date:
Late Arrival and Cancellation Policy When requesting an appointment, time and resources are made available to provide a treatment.
You will receive a reminder phone call prior to your appointment. Late arrival will cut into the treatment time allotted and you will be charged for the time originally booked. In the instance that the RMT is late, you will receive your full treatment time.
Please cancel your service 24 hours prior to your appointment. Appointments cancelled with less than 24 hours notice WILL be charged IN FULL at the discretion of the therapist. Your cooperation is greatly appreciated.
I ______am aware of, and accept this policy.
Signature:______Date: