Confidential Medical History Form

I Understand that I must disclose if I: 

  1. Have one or more of the below symptoms:
    • Fever, cough, sore throat, shortness of breath/breathing difficulties
    • Other symptoms such as muscle aches, fatigue, loss of smell or taste, headache, runny nose, hoarse voice, nausea, vomiting or diarrhea
  2. Have travelled outside of Manitoba in the last 14 days
  3. Have had close contact (face-to-face contact within 2 meters/6 feet) with someone who is ill with cough and/or fever who has travelled outside of Manitoba within 14 days prior to their illness onset (contact may be in Canada or during travel)
  4. Have been in contact in the last 14 days with someone who is confirmed to be a case of COVID-19
  5. Have had laboratory exposure while working directly with specimens known to contain COVID-19





NoYes



NoneLowModerateHigh


NoneLowModerateHigh


NoneLowModerateHigh


NoneLowModerateHigh


NoneLowModerateHigh




NoYes



CancerDiabetesSurgery

I no longer have cancer.



Irritable bowel syndromeColitisCrohn's


TensionMigraineHead traumaT.M.J (Jaw pain)Neurological conditionChronic pain condition



High/low blood pressureHeart attackStroke/CVAPhlebitis/DVTPulmonary emboliPace makerHeart diseaseVaricose veinsChronic congestive heart failureFamily history of the above


Osteoarthritis, Rheumatoid, ArthritisFractures, breaks or dislocation


WellnessStressPainInjury

By clicking "Submit" I state that the above information provided is accurate to the best of my knowledge, and understand that this information will be kept confidential. I understand that the RMT is providing massage therapy services within their scope of practice defined by the Massage Therapy Association of Manitoba.

I understand that massage therapy is not a replacement for a medical examination and my RMT is not a Doctor. I understand that I shall seek medical attention for any ailments that I may be experiencing. I understand that the therapist must be aware of any existing medical conditions prior to the massage therapy treatment and I agree to inform the therapist of any new conditions that may arise in the future.

I acknowledge that no assurances or guarantees are provided to me as to the results of the treatment. I acknowledge that with any treatment there can be a risk and those risks have been explained. I understand that despite the RMTs best efforts to take appropriate precautions, that there is a possibility that I could come in contact with the COVID-19 virus. I agree that Anchor Massage Therapy or the RMT will not be responsible or liable of any COVID-19 related injuries, illnesses or death as a result of this from this or future massage therapy treatments. I also understand that I can stop the treatment at any time. I also give consent to receiving massage therapy treatment at Anchor Massage Therapy for present and for any future condition(s).