Looking for the Best Physical Rehab?

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

Facebook Instagram Youtube Linkedin

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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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 (If Chkd)

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

Other Conditions:

Loss of sensation, where?

Diabetes, onset:

Allergies List?

Cancer where?

Skin conditions?

Arthritis:

Osteoporosis:

Women:

Pregnant, due?

Gynecological conditions List:

Overall, how is your general health?

Very Good

Good

Fair

Poor

Current Medications:

Conditions Meds treat:

Are you currently receiving treatment from another health care professional?

Yes

No

If yes, for what?

Surgeries?

Yes

No

Date:

Metal Implants (pins, plates, artficial joints?

Yes

No

Location:

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

Yes

No

Please List:

What is the reason you are seeking physical/massage therapy? Please include the location of any tissue or joint discomfort.

Request an Appointment

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