Medical History Intake – Cassandra Southall RMT

Name *

First

Last

Email *

Street Address *

Street Address 2

City *

Province / State *

Postal / Zip Code *

Check the conditions that currently or in the past apply to you: *

Have you had any surgeries? *

If you answered "Yes" to the previous question, please provide details including when and for what reason?

Check each of the symptoms you are currently experiencing: *

What is your main reason for seeking treatment? *

On a scale of 1-10 what is your current level of pain? *

Are you currently taking any medication? *

If you are taking any medication, please note which one(s) below:

What is your gender? *

Do you use or do you have a history of using tobacco? *