An image of a patient holding a pen and reading a health history form.

Health History Guidance

June 2024

Health history questions are important for setting the stage for effective and client-centred treatment. CMTO’s Guide to Record Keeping Requirements outlines the minimum amount of information that must be collected and documented in a client’s health record.

In addition to minimum requirements, health history forms (CMTO’s previous health history template included) have suggested that RMTs collect information about specific infections (such as herpes, tuberculosis, and HIV), a list of all current medications and gynecological conditions.

Over the past two years, CMTO has asked RMTs to stop asking about HIV/AIDS status, discussed this issue at its Open Houses, and brought together a focus group of RMTs to review proposed guidance on gathering Personal Health Information.

This feedback was essential in helping our staff create a guide with general recommendations for collecting personal health information, and also to identify the type of Personal Health Information that RMTs:

  • Cannot request from clients;
  • Can only ask clients under specific circumstances; and
  • Can ask every client.

The draft Health History guidance is currently under review and will be shared as part of a public consultation later this year. Once the guidance is approved, we plan to release it early in 2025. Stay tuned for more information!

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