Current Medication & Nature Injury History

_____________________________________
Date: 1 month ago
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Nature: Meniscus, lateral collateral ligament & anterior cruciate ligamen
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Date: _______________________
_____________________________________
Nature: _____________________
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Physician
Name: _______Dr. Health______
Surgery History Address: ___123 Doctor Lane___
Date: _3 weeks ago___
Nature: ___repair meniscus_________ Present Involvement in other care? (circle)
Date: _______________________ YES NO
Nature: _____________________ If Yes, please specify:

Other medical conditions (mood or sleep disorders, haemophilia, etc):

__________________________________________________________________________________________

Special notes (internal pins, artificial joints, special equipment, etc):

__________________________________________________________________________________________

Please read and sign. If you have any questions, please ask.

I, ___Neil Manisce______________________________ understand that all the information I have provided on

this health history form is true, and that I will report to the therapist if there are any changes to my health or
information necessary for the form.
“Pursuant to Section 39 (2) of the Freedom of Information and Protection of Privacy Act, you are hereby notified
that personal information relating to you being collected in this Massage Therapy Clinic Health History Form
which will be used to facilitate your treatment at the clinic.
I hereby authorize this Massage Clinic to use the information as described above to facilitate my treatment.

Signature of Client: _________________Neil Manisce___________

Date: ____November 1st, 2010________________

Health History Updates

Change Date Initial
__________________________________________ _____________________ ______
__________________________________________ _____________________ ______
__________________________________________ _____________________ ______
__________________________________________ _____________________ ______
__________________________________________ _____________________ ______