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Health form, Massage therapy
HEALTH QUESTIONNAIRE
MASSAGE THERAPY, PHYSIOTHERAPY, ORTHOTHERAPY
Personal details
Gender
Madam
Mister
Date of birth
DD
MM
YYYY
Name
*
First name
*
Telephone (residential)
Cell phone
Office Phone
Email
*
Occupation
Adress
Adress
City
ZIP code
Survey
Date of the first meeting
DD
MM
YYYY
Insurance
Oui
Non
Reason for consultation
Have you consulted a doctor about this?
Yes
No
If yes, what diagnosis did you have?
Have you ever consulted a therapist?
Yes
No
If yes which ?
What are your expectations regarding treatment?
Are you pregnant ?
Yes
No
Date of Birth
DD
MM
YYYY
Is your pregnancy at risk?
Yes
No
If so, what are the risks?
Are your periods
Regular
Irregular
Menopause
If you are in menopause, what are the symptoms?
Do you suffer from :
Digestive problems
Diabetes
Hypoglycemia
Other
If other, please specify :
Do you take medication
Yes
No
If yes which ?
Have you ever had operations, fractures?
Yes
No
If yes which ?
Have you ever had an accident?
Oui
Non
If yes which ?
Do you have heart or circulation problems?
Hypertension
Hypotension
Palpitations
Infractus
Angina
Stroke
Varices
Phlebitis
Atherosclerosis
Arteriosclerosis
Hemophilia
If yes, when?
Stroke: if yes, when?
Varicose or Phlebitis: if yes, where and when?
Do you have breathing problems?
Asthma
Diabetes
Emphysema
Allergy
Other
Please specify
Do you have any :
Migraines
Regular headaches?
Please specify :
Do you suffer from :
Tiredness
Insomnia
Stress
Other
If other, please specify:
Do you have cancer?
Yes
No
If yes, what is it?
Do you wear :
Orthotics
Contact lenses
Prosthesis
Other
If other, please specify :
Do you eat a healthy and balanced diet?
Very
Moderately
Not at all
What are your sports and leisure activities?
The purpose of this health questionnaire is to obtain information on your health status in order to adapt our care to your situation. Although this questionnaire is for advisory purposes only, failure to report any information could affect your follow-up. In this case, the professional liability of the principal could not be engaged. In this context, it would be helpful if you could carefully complete this questionnaire.
*
I have filled out the form
Signature
Date
DD
MM
YYYY
Our services
Thermal experience and packages
Massages
Aesthetics and facials
Health form, Massage therapy
Aesthetic health form
Schedule and info
Promotions
Shop
Booking
Français
