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

September 27th 2021

Change Your Pain Kamloops is an interdisciplinary health, wellness, and physical rehabilitation facility. A Kamloops-based pain clinic, we join you on your wellness journey with a commitment to 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.

Here’s everything you need to know to fill it out correctly.
Note: Throughout the form you will see the acronym “RMT.” That means Registered Massage Therapist.

    • 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.

    • 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, so we can offer a holistic approach to treatment taking into consideration your past medical history.

    • Next 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.

    • 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 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.

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

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

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.