How to Fill Out Your Forms

How to Fill Out Your Patient Initial Intake Form & Patient Referral Form

The road to recovery is not always smooth. We are here to help you on your journey which starts with how to fill out your forms.

At Change Your Pain Kamloops, we are committed to helping make the process as simple as possible. We want to support you as effectively and efficiently as we can and knowing a little about you and your medical history helps ensure the intake process is smooth and informative. For this reason, we ask that you fill out our RMT Patient Intake Form – also known as a Confidential Patient History Form – prior to your first appointment.

How to Fill Out Your Forms Correctly

Please note: Throughout the form, you will see the acronym “RMT.” That means Registered Massage Therapist.

1. Basic Information

The first portion of the form is straightforward. We need to know your name, age, address, etc. as well as how you heard about Change Your Pain Kamloops.

2. Your Needs

Next, we need to know if you are dealing with an accident-related injury involving an ICBC claim, or a work-related injury involving a WCB claim. If it is either of those things we need to know in advance so we can complete the necessary steps to help ensure your claim is supported successfully.

It is helpful for us to know what other treatments you have had in the past and when they happened. Knowing this in advance helps open a conversation related to your past therapies. We can offer a holistic approach to treatment taking into consideration your past medical history.

3. About You

We would like to know your favourite activities, sports, or hobbies. This helps us identify possible correlations between activities and pain and helps us form a treatment plan to help get you back to doing the things you love to do.

Prior to treatment, we need to know what/if any conditions apply to you. Please read over the list carefully and answer honestly so we can plan appropriate treatment. We also need to know any medications, supplements, or pain relievers you are presently taking as well as known allergies, family history of medical conditions, and a few details on past hospitalizations, accidents, illnesses, and/or surgeries.

4. How You Feel

The final section of the form relates to how you are feeling right now. Please take a few minutes to think about your lifestyle, your current condition and symptoms, and how long you’ve been experiencing symptoms, so we can begin to formulate a treatment plan.

Please fill in the diagram with the appropriate symbols. They are used to indicate where pain is occurring and what type of pain it is. This will help your RMT understand what you are currently dealing with and provide a starting point to plan your treatment.

5. Double Check and Sign

Finally, we ask you to read over and sign the waiver.

6. Email Us

Once you’ve completed the Patient Initial Intake Form, please email it back to us at or print it and bring it to your first appointment.

Thank You for Learning How to Fill Out Your Forms

At Change Your Pain Kamloops, our goal is to educate, restore movement, and improve quality of life. We believe that massage therapy works and are committed to improving the lives of our clients. Completion of this form helps us get started on that journey together.

Please Contact Us if you have any questions.

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