Name ______________________________________________________     Birth date (MM/DD/YYYY) ___________________
Address _____________________________________________________________________    Suite ___________________
City, Province __________________________________________________________     Postal code ___________________
☎ (Day) ______________________     ☎ (Evening) ______________________     E-mail _____________________________
Your occupation __________________________________________     Who referred you? ____________________________
Physician name & address ________________________________________________     Extended health care?   Yes   No

SYMPTOMS
Sensation   sharp   dull   achey   throbbing       burning   numb(pins & needles)   other _______

Frequency   rarely   comes & goes   frequent         constant

What is the intensity of this discomfort?
0    1    2    3    4    5    6    7    8    9   10(intolerable)

please mark areas of symptoms
HEALTH HISTORY   current conditions   previous experience
MUSCLE SKETETAL & NERVES
tension or migraine headaches
whiplash / motor vehicle accident
neck or shoulder pain or stiffness
back or hip pain or stiffness
upper limb weakness or tingling
lower limb weakness or tingling
head trauma or concussion
loss of co-ordination or dizziness
sleep or personality changes
light-headness / fatique
epilepsy/ seizures
TMJ or tooth, jaw or ear pain
vision or hearing difficulty or loss
degenerating disease
osteo or rheumatoid arthritis
osteoporosis or bone disease
spasm & strain or sprain
tendonitis, fibrositis or bursitis
fractures / pins, wires, plates
carpal tunnel syndrome
loss of sensation
HEART & CIRCULATORY SYSTEM
blood pressure high or low
chronic congestive heart failure
heart disease/attack or stroke CVA
chest pain or angina
pacemaker or similar device
varicose veins or phlebitis
cold hands & feet or swelling
diabetes
poor healing/ bruise easily

CIRCLE YOUR OVERALL HEALTH
poor 1 2 3 4 5 6 7 8 9 10 excellent		 SKIN & IMMUNE SYSTEM
open sores, cuts or warts
contagious skin disease
tuberculosis or hepatitis
HIV
cancer
allergies (food, environmental)
BREATHING SYSTEM
asthma
bronchitis or emphysema
shortness of breath
frequent colds or sinus
chronic cough /smoking
DIGESTIVE SYSTEM
nausea or vomiting
constipation
rapid weight loss
appetite changes
diarrhea
bad taste in mouth
irritable bowel
ulcers
gall bladder problems
GENITOURINARY SYSTEM
painful urination
unusual color /odor
hip or flank pain
gynecological concerns
pregnant? due date _____
LIFE STYLE
have children? ages _____
smoking or alcohol
regular exercise
coffee or tea 3+cups/day
poor sleeping patterns

Prominent family illnesses _______________________________________________________________________________
Current medications __________________________________________    Other treatments __________________________
Major injuries or surgeries __________________________________________________________    Year(s) ______________
I understand that all information gathered for this treatment is confidential, except as required or allowed by law or except to facilitate diagnosis(assessment) or treatment. I understand I will be asked for written authorization for release of any information outside my circle of care. I have reviewed the fee schedule and cancellation policy, and I understand I must give at least 24 hours notice to reschedule my appointment. I will inform my therapist should anything change regarding my health status

Today's Date (MM/DD/YYYY) ________________    Signature __________________________________________________
we regard your privacy seriously. Please ask for a copy of our privacy policy, or visit www.junrmt.com