R. Bruce Winstone Massage · Rolfing® · Alexander Technique

Confidential

Patient history

Please fill this in before your first visit. It takes about 10 minutes. It's sent securely and locked with a key only I hold, so it can only be opened on my own computer.

Fields marked * are required. Everything else, answer what you can.

1 About you
2 Emergency contact
3 Your health care
Is this an ICBC or WorkSafeBC claim?
4 Health history

Mark anything that applies to you now (Current) or in the past (Past). Leave the rest.

Heart & circulation

Heart attack
High or low blood pressure
Stroke or aneurysm
Pacemaker
Other heart condition
Varicose veins
Bruise easily
Other circulatory condition

Nervous system

Headaches / migraines
Dizziness / fainting
Nausea
Spinal injury
Head injury
Epilepsy / other seizures
Other neurological condition

Mood

Anxiety
Depression

Breathing

Asthma
Chronic sinusitis
Other respiratory condition

Digestion, kidneys & skin

Diabetes
Kidney disease
Other urinary condition
Irritable bowel / colitis
Digestive condition
Skin condition

Bones & joints

Joint dislocation
Bone fracture
Arthritis
Osteoporosis
Rods / pins / plates / shunts
Implants
Transplant

Other

Cancer
Hepatitis
HIV
Other contagious condition
Corrective lenses / contacts
Pregnant, or might be
Any family history of medical conditions?
Have you ever been in hospital, or had a major accident, illness or surgery?
5 Other care you've had

Past or present, whether or not it's related to this visit.

6 Day to day

How do you feel right now? 1 = poor, 5 = excellent

Quality of sleep
Energy level
Eating habits
Stress level
Exercise habits
Smoker
Alcohol
7 What brings you in

Where do you feel it?

Pick a kind of symptom, then tap the body where you feel it. Tap again to remove it.

Front
Your rightYour left
Back
Your leftYour right
    8 Consent

    Please note: your appointment time has been reserved for you. As a courtesy to your therapist and other patients, please give at least 48 hours' notice of cancellation, or a cancellation fee will be charged. Payment for all treatment, whether private or insured, is ultimately the responsibility of the patient.

    I authorize R. Bruce Winstone, RMT, to collect my personal and medical information as documented above in order to contact me, and give permission to leave messages regarding appointments at any of the contact numbers I have provided above. In addition, I authorize him to communicate with my referring MD as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission. How it is stored is described in the privacy policy.

    Date