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Call : +1 (416) 249-8668

Email : info@trinityrehab.ca

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Looking for the Best Physical Rehab?

Call : +1 (416) 249-8668

Email :info@trinityrehab.ca

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About Us
Our Services
Patient Center
- Forms
Contact Us
FAQ

About Us
- Who We Are
- Our Team
- Careers
- Gallery
Services
- Core Services
- What We Treat
Patient Center
Contact Us
Blogs

Looking for the Best Physical Rehab?

About Us
Our Services
Patient Center
- Forms
Contact Us
FAQ

About Us
Our Services
Patient Center
- Forms
Contact Us
FAQ

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TPh. 416-249-8668, Fax. 416-249-5794, Email:info@trinityrehab.ca
1 723 Kipling Ave. Unit#9, Etobicoke, ON M9R4E1
www.Trinityrehab.ca

HEALTH HISTORY FORM

In order to ensure optimum care in therapy, this form is to be completed by each patient. All information will remain confidential and be part of your therapy program. Feel free to ask any questions about the information being requested.

Name:

Date:

Please indicate conditions you are experiencing or have experienced:

Cardiovascular:

High blood pressure

Low blood pressure

Congestive heart failure

Heart attack

Phlebitis/varicose veins

Stroke/CVA

Pacemaker or similar device

Heart disease

Infections:

Hepatitis

Skin conditions

TB

HIV/AIDS

Herpes

Covid-19

Date of Infection:

Report Date:

Head/Neck/Body:

History of headaches

History of migraines

Vision problems

Ear problems

Hearing loss

Chronic Neck Pain

Other Chronic Pain

Respiratory:

Chronic cough

Shortness of breath

Bronchitis

Asthma

Emphysema

Women:

Pregnant

Gynecological conditions

Pregnant, due:

What Gynecological conditions?

Other Conditions:

Loss of sensation

Diabetes

Allergies

Epilepsy

Cancer

Skin conditions

Arthritis

Osteoporosis

Loss of sensation where?

Diabetes, onset:

Allergies List?

Cancer, where?

Skin conditions?

Do you have any other medical conditions? (e.g. digestive conditions, haemophilia, mental illness):

Yes

No

Please List:

Overall, how is your general health?

Very Good

Good

Fair

Poor

List previous injuries:

Are injuries the result of (MVA) Motor Vehicle Accident:

Yes

No

If yes, Date of Loss or Accident:

(WSIB) Workplace Safety Injury Benefits?

Yes

No

If yes, Date of Loss/Accident:

Current Medications

Conditions Meds treat:

Are you currently receiving treatment from another health care professional?

Yes

No

If yes, for what?

Surgeries?

Yes

No

Type/Date:

Metal Implants (pins, plates, artificial joints?

Yes

No

Location of implant:

What is the reason you are seeking physical/massage therapy?

Please include the location of any tissue or joint discomfort:

Signature:

Request an Appointment

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