Relax, rejuvenate, and restore - Your one-stop wellness solution!
OmniHealth Wellness
Home
Services
rmt massage treatment
acupuncture treatment
Locations
Book online
Blog
Shop
Book an appointment
Search for:
Search
Initial Health Record
Home /
Initial Health Record
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Patient Name
*
First
Last
Email
*
Date of Birth
*
Sex
*
Male
Female
Prefer not to say
Date of Intake
*
Cell Phone Number
*
Home Phone Number
Work Phone
Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
--- Select country ---
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Kingdom of)
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Current or Previous Occupation
*
EMERGENCY CONTACT INFORMATION
Emergency Contact's Name
*
First
Last
Contact Number
*
Relation to Patient
*
Current Healthcare Provider Contact Information
Please add a contact phone number and email address
Family Doctor's Name
First
Last
Family Doctor's Phone
Family Doctor's Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
--- Select country ---
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Kingdom of)
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
CONDITIONS
Do you have any conditions?
Yes
Area of Complaint
Left Side of Neck
Right Side of Neck
Left Side of Upper Back
Right Side of Upper Back
Left Side of Mid Back
Right Side of Mid Back
Left Side of Low Back
Right Side of Low Back
Chest
Abdomen
Left Arm
Right Arm
Left Shoulder
Right Shoulder
Left Elbow
Right Elbow
Left Wrist
Right Wrist
Left Hand
Right Hand
Left Leg
Right Leg
Left Hip
Right Hip
Left Knee
Right Knee
Left Ankle
Left Foot
Right Foot
Headaches
Migraines
Headaches
Cluster
Rebound
Sinus
Chronic Daily Headache
Tension
Neurological
Tingling
Multiple Sclerosis
Brain Injury
Stabbing
Cerebral-vascular Accident
Cerebral Vascular Accident(Stroke)
Sciatic Pain
Loss of Sensation
Seizure Disorder
Stroke
Transient Ischemic Attacks(TIA)
Vertebral and Spinal Cord Injury
Epilepsy
Shingles
Cerebral Palsy
Huntington Disease
Dizziness
Parkinsons
Brain Disorder
Numbness
Burning
Herniated Disc
Chronic Pain Disorder
Cardiovascular
Cardiovascular Conditions
Congenital Heart Defect
Varicose Veins
Heart Attack
Blood Pressure
Acute Coronary Syndrome
Coronary Artery Disease
Blood Clots
Phlebitis
Aneurysm
Hyperlipidemia
Lymphedema
Cardiovascular Accident
Angina
Pericarditis
Pacemaker
Atherosclerosis
Raynaud Disease
Cold Hands
Heart Disease
Cardiac Arrhythmia
Rheumatic Heart Disease
High Blood Pressure
Cold Feet
Chronic Ischemic Heart Disease
Valve Disorder
Low Blood Pressure
Chronic Venous Insufficiency
Myocardial infarction
Congestive Heart Failure
Reproductive
Menstrual Cycle Disorder
Ovarian Cysts/ Tumors
Pelvic Inflammatory Disease
Premenstrual Syndrome
Pregnancy
Uterine Disorder
Gynaecological Conditions
Breast Disorder
Ectopic Pregnancy
Endometriosis
Menopause
Immune
Non-Hodgkin Lymphoma
Rheumatoid Arthritis
Anaphylaxis
Allergies
Lupus
Hodgkin Lymphoma
Infectious Mononucleosis
Cancer
Leukemia
Musculoskeletal
Hereditary/Congenitial Deformity
Strain/Sprain
Joint Injury
Amyotrophic Lateral Sclerosis (ALS)
Osgood-Schlatter Disease
Osteoporosis
Muscular Dystropy
Osteoarthritis
Ankylosing Spondylitis
Gout
Osteomalacia
Myasthenia Gravis
Tendonitis/Bursitis
Bone Disease
Paget Disease
Sinus Problems
Compartment Syndrome
Psoriatic Arthritis
Artificial Joints/ Special Equipment
Dislocation
Scleroderma
Fibromyalgia
Fracture
Arthritis
Jaw Pain(TMJD)
Scoliosis
Gastrointestinal
Constipation
Digestive Conditions
Poor Appetite
Diarrhea
Stomach Disorder
Crohn's Disease
Diverticulitis
Ulcerative Colitis
Eating Disorder
Esophageal Disorder
Fecal Impaction
Intestinal Polyps
Celiac Disease
Irritable Bowel Syndrome
Blood
Hyper coagulability
Hepatities
Polycythemia
Haemophilia
HIV
Thrombosis/Embolism
High Cholesterol
Anemia
Bleeding Disorder
HIV/AIDS
Skin
Acne
Athlete's Foot
Psoriasis
Allergic Dermatosis
Rash
Bruise Easily
Athletes Foot
Herpes
Hypersensitive Reaction
Rosacea
Chemical Burn
UV Burn
Hypersensitive Reactions
Melanoma
Melanoma/Carcinoma
Skin Conditions
Infectious Skin Conditions
Pigmentary Disorder
Skin Irritations
Plantar's Wart
Respiratory
Chronic Cough
Respiratory Conditions
Shortness of Breath
Asthma
Tuberculosis
Emphysema
Bronchities
Respiratory Tract Infection
COPD
Cystic Fibrosis
Infectious Respiratory Conditions
Hearing
Conductive Hearing Loss
Meniere Disease
Motion Sickness
Tinnitus
Ear Problems
Vertigo
Hearing Loss
Kidney
Renal Cysts
Urinary Incontinence
Urinary Tract Infection
Bladder Disorder
Chronic Kidney Disease
Congenital Kidney Disease
Electrolyte Imbalance
Kidney Stones
Endocrine
Acute Pancreatitis
Diabetes
Hyperthyroidism
Pituitary and Growth Disorder
Prostate Condition
Family History
Arthritis
Cardiovascular
Respiratory
Miscellaneous
Vision Problems
Vision Loss
Mental Health Issues
Surgical Pins or Wire
Insomnia
Other Medical Conditions
Other Diagnosed Diseases
MEDICATIONS
How many medications do you have now?
Selected Value:
0
Medication
Comment
Medication
Comment
Medication
Comment
Medication
Comment
Medication
Comment
Medication
Comment
Medication
Comment
Medication
Comment
INJURIES
How many times have you been injured?
Selected Value:
0
Injury
Comment
Injury
Comment
Injury
Comment
Injury
Comment
Injury
Comment
Injury
Comment
Injury
Comment
Injury
Comment
SURGERIES
How many surgeries have you had?
Selected Value:
0
Surgery
Comment
Surgery
Comment
Surgery
Comment
Surgery
Comment
Surgery
Comment
Surgery
Comment
Surgery
Comment
Surgery
Comment
ADDITIONAL INFO
Have Have You Had a Theraputic Massage Before?
Yes
No
Are You Currently Under Care of a Physcian/Chiropractor?
No
Yes
If yes, please detail the reason
Current Exercise/Training Routine
Please detail your current exercise schedule
Medication or Tension,
Please Detail Any Current Pain, Tension, or Discomfort Areas
Arm, leg, neck, etc.
Insurance
I have insurance
Insurer
Blue Cross
Canada Life
Chambers of Commerce
Desjardins
Equitable
Green Shield Insurance (GSC)
Industrial Alliance (IA)
Manulife Financial
People Corporation
RBC
The co-operators
Policy Name
Policy / Group / Plan #
Member ID / Certificate
Other Insurer not list above
Policy Holder
I'm not the policy holder
First Name
Last Name
Relationship To Patient
Child
Parent
Spouse
Common Law Spouse
Other
Date of Birth
Address
City
Prov/State
Postal / Zip Code
Phone Number
FINAL STEPS
Terms & Conditions
*
I hereby agree to the following terms and conditions:
Welcome to OmniHealth. Because the Terms and Conditions contain legal obligations, please read them carefully.
1. YOUR MASSAGE AGREEMENT
By agreeing to this, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use click agree.
PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.
2 YOUR Traditional Chinese Medicine or Acupuncturist AGREEMENT
I understand that some of the techniques used under the scope of Traditional Chinese Medicine include the use of sterile, single-use needles to penetrate the skin. Additional treatment methods can include, but are not limited to: acupuncture, acupressure, the electrical stimulation of needles, cupping or moxibustion, gua sha, and tuina. Before any of these procedures are performed, my practitioner will discuss my treatment options and only processed if my consent is given.
My practitioner has informed me the risks and symptoms of treatments, which can include, but are not limited to: slight pain, light-headedness or nausea, soreness, bruising, bleeding or discoloration of the skin, and the possibility of other unforeseen risks. I freely accept the risks involved with my procedure.
I will inform my practitioner if I currently have or develop any major health issues, if I suffer from any type of major bleeding disorder, or if I use a pacemaker.
I understand that I must let my practitioner know I am carrying, or believe to have any infectious agents, including but at not limited to HIV, TB and Hepatitis. In some cases where cross-infection is high, my practitioner may withhold treatment.
I understand that there are no guarantees for the results of my treatment. Traditional Chinese Medicine does not often provide an instant cure. The length of my treatment depends on the severity of my condition. In some cases my symptoms may temporarily worsen before they begin to improve.
I understand that the fees charged for my treatment are not covered under OHIP and must be covered in full by myself or through third party insurance. I am responsible for the full and prompt payment after services have been rendered.
I discuss the content of this form with my practitioner. I acknowledge that I can ask any questions I may have and receive answers I understand. By signing this form, I give my informed consent for Traditional Chinese Medicine treatments.
3. PRIVACY
Your information will be logged in our system and will not be shared with 3rd parties.
Client Signature
*
Clear Signature
How Did You Hear About Us?
Google
Ins
Yop
WeChat
Red Book
Facebook
TikTok
51
Superstore
Additional Questions or Comments
Submit
0
BOOK AN APPOINTMENT