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INTAKE FORM

Precautions and Contraindicationsc

Massage Therapy:

Precautions: Warfarin – anticoagulant medications, Varicose veins, Cancer, Open sores, Active infection, Recent airplane travel (<2 weeks)

Contraindications for 1st Trimester of Pregnancy:

– History of bleeding
– Abdominal pain
– Nausea or hyperemesis gravidarum
– Fever and malaise
– Pre‐existing high risk condition prior to pregnancy, including but not limited to, diabetes, kidney, hypertension and cardiac disease 

– History of previous miscarriage
– Poor outcome in previous pregnancy
– Previous late term loss (past 20 weeks gestation)
– Placental abruption in previous pregnancy

Spinal Adjustment/Manipulation:

Precautions: Vertebral Artery Occlusion or Insufficiency, BPPV, Vertigo, Dizziness

Contraindications:

– Abnormalities such as dens hypoplasia, unstable os odontoideum,
etc.
– Acute fracture
– Spinal cord tumour
– Acute infection such as osteomyelitis, septic discitis, and tuberculosis
of the spine
– Meningeal tumour
– Haematomas, whether spinal cord or intracanalicular
– Malignancy of the spine
– Frank disc herniation with accompanying signs of progressive
neurological deficit
– Basilar invagination of the upper cervical spine
– Arnold‐Chiari malformation of the upper cervical spine
– Dislocation of a vertebra

– Aggressive types of benign tumours, such as an aneurismal bone
cyst, giant cell tumour, osteoblastoma or osteoid osteoma
– Internal fixation/stabilization devices
– Neoplastic disease of muscle or other soft tissue
– Positive Kernig’s or Lhermitte’s signs
– Congenital, generalized hypermobility
– Signs or patterns of instability
– Syringomyelia
– Hydrocephalus of unknown aetiology
– Diastematomyelia
– Cauda equina syndrome

Acupuncture / Dry Needling:

Precautions: Acupuncture should be used with caution on pregnant patients

Bracing / Taping / Casting:

Contraindications:
– Allergy to taping materials
– Open wounds
– Active infection or irritation of area of skin to be taped
– History of hyper sensitive skin or pre-existing skin conditions e.g.;
psoriasis, eczema, dermatitis

– Circulation compromised in area
– Sensation compromised in area
– No one available at home to remove tape, plaster, brace if it causes
irritation or discomfort