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Ross Banerjee, Registered Massage Therapist
Health History Form
Massage Therapy is the manipulation of the soft tissues of the body to gain a therapeutic response. Soft tissues include muscles, tendons, ligaments, and fascia.
When you're in the room with Ross, you are the boss. This means that at all times you are the one who is in control and one who is most comfortable. If he does, says, looks like, or smells like anything you are not comfortable with, please let him know. He will ask you, from time to time, if you are comfortable, but on occasion, things may come up that neither he nor you expect, that require attention. Please let him know, as his ability to read minds is not what it once was … if it ever was.
In order to relieve pain, it may be necessary to recreate some of the pain you walked in with. However, Ross does not want to recreate so much pain that you will be hurt or bruised as a result of the treatment. So, he likes to use a pain scale between 1 and 10. One is virtually nothing; ten is passing out. At 5/10, you begin to hold your breath in an uncontrollable manner. If this happens, the treatment is too deep, and you must tell him to modify his treatment so that you will feel less than that 5 out of 10 pain level. This lower pain level will still treat the sore spot, however it will take longer to treat, but the end result should be that your pain disappears for longer without the annoying side effects of soreness after the massage.
During this first visit, you will be asked for a confidential health history. According to the relevant privacy laws, all health information shall be stored in a locked cabinet and shall not be shared with anyone, unless you give specific permission.
When you're getting on the table, please note, Ross does doesn't care whether you wear all your clothes or not. Massage does work best skin on skin, but massage also works best when you are comfortable, so if you are not comfortable disrobing, then you are under no obligation to do so. While under the sheets, Ross will only undrape (uncover) the areas he is working on, and only uncover them to your comfort level. If, during the course of the treatment, you feel uncomfortable with the level or style of draping, please tell Ross.
On the table, or on the chair, Ross will perform Swedish, fascial, trigger point, and a variety of other techniques, depending upon your needs.
In between sessions, sometimes Ross will offer instruction on remedial exercises. These exercises or stretches will be specifically chosen to help you to keep you as limber and pain free as possible. You live in your body 24 hours a day, 7 days a week, whereas Ross may only be working on you once, twice, thrice, or less or more times per month, for about an hour at a time. This means that while you know yourself better than Ross does, a single massage can only be so helpful. Your exercises and stretching will go a long way to ensuring that the massage, or massages, will be as effective as possible, in the long run.
COVID-19 Questions - The following criteria need to be met in order for you to be seen today. You have NOT been experiencing any of the following symptoms of COVID-19 currently or in the last 14 days. Part 1 of 3
Unexplained muscle aches
Runny Nose or nasal congestion without known cause
Decreased or lost sense of taste or smell
None of the above
COVID-19 Questions Part 2 of 3
I have not travelled out of the country in the last 14 days.
I acknowledge that I have not knowingly been in contact with anyone who has symptoms or has tested positively for COVID-19 in the past 14 days.
COVID-19 Questions Part 3 of 3
I confirm all of the above COVID-19 Questions are true and correct. Please type your NAME, your PHONE NUMBER. Please contact me if you develop any COVID-19 symptoms within 14 days of seeing me.
Rates - HST 84636 9759 RT0001
Credit Card (American Express, Discover, Master Card, VISA, etc.)
Cheque (made out to Ross Banerjee)
Massage Duration and cost
¼ hour $30
½ hour $50
¾ hour $70
1 hour $90
1 ¼ hours $110
1 ½ hours $130
1 ¾ hours $150
2 hours $170
On a scale of 1-10, where 10 is passing out, what is your pain level today
Musculoskeletal System: What hurts? Please indicate in "Other…" which symptom is in your history (not happening now), and/or add any details not specifically asked for.
Circulatory System: What is happening now? Please indicate in "Other…" which symptom is in your history (not happening now), and/or add any details not specifically asked for.
High Blood Pressure
Low Blood Pressure
Nervous System: What is happening now? Please indicate in "Other…" which symptom is in your history (not happening now), and/or add any details not specifically asked for.
Skin Conditions: What is happening now? Please indicate in "Other…" which symptom is in your history (not happening now), and/or add any details not specifically asked for.
Digestive Conditions: What is happening now? Please indicate in "Other…" which symptom is in your history (not happening now), and/or add any details not specifically asked for.
Kidney / Bladder
Irritable Bowel Syndrome
Immune System: What is happening now? Please indicate in "Other…" which symptom is in your history (not happening now), and/or add any details not specifically asked for.
Handedness: Which is your dominant hand?
Other concerns. Please indicate in "Other…" which concerns you are experiencing now, and/or add any details not specifically asked for.
What is your main complaint? Please type any specifics in "Other…".
Are you getting treatment by any other Health Care Practitioner? Please indicate in "Other…" if you need to specify more than that which is given.
Traditional Chinese Medicine
How effective is the treatment?
How much recreational activity do you do?
What stretches and/or exercises do you do?
Home address (# street, city, province, postal code)
Phone (work) -- Please star (*) which is your preferred mode of contact
Text / Phone (mobile) -- Please star (*) which is your preferred mode of contact
Email -- -- Please star (*) which is your preferred mode of contact
Occupation (I use this information to determine what postures you might be in for the majority of your day)
Date of Birth
Doctor's Name / Address / Phone
COVID - Tested / Vaccinated
Negative test results within 14 days
Negative test results within 7 days
Positive test results within the last 14 days
Client Agreement and Declaration -- In the section "Other…" please state any restrictions to consent.
If there is reasonable and sufficient cause, my therapist has the right to refuse to treat me. If he refuses, he will state the reason and give a treatment alternative or a remedy for my current circumstances.
I certify that all the above information is true and that I will notify my therapist of any changes. My therapist will verify any changes to health data each year.
I have read and understood the above document. Anything I did not understand, my therapist has explained to my satisfaction.
I confirm that I am capable of consenting to treatment. I acknowledge that consent is voluntary and I understand that I may withdraw my consent at any time during the assessment, treatment, or treatment plan.
I hereby consent to participate in this therapeutic relationship.
Digital Signature (Please type your name + Day/Month/Year)
Send me a copy of my responses.
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