Standard of Practice: Collecting Personal Health Information from Clients
This Standard comes into effect November 1, 2025.
Bolded terms below are found in the Glossary.
Client Outcome
The Registered Massage Therapist/Massage Therapist (RMT/MT) asks the client to share the Personal Health Information (PHI) that is necessary for Massage Therapy care. The client is protected from requests for sensitive or unnecessary PHI that could result in harm, stigmatization, or discrimination. The client has a right to control how the RMT/MT collects, uses, and/or discloses their PHI.
Registered Massage Therapist Outcome
The Registered Massage Therapist/Massage Therapist collects PHI from the client using professional judgment and a client-centred approach to only collect information necessary to provide safe and effective care.
Requirements
CMTO requires RMTs/MTs to use a client-centred approach to:
- Inform clients about PHI collection practices, including the client’s right to give, withhold, or withdraw consent to the collection, use, or disclosure of their PHI.
- Only collect information reasonably needed to provide safe and effective Massage Therapy treatment.
- Ensure different clients’ needs and preferences are met by offering more than one option for PHI collection, including verbal, written, electronic, or through a combination of approaches.
- Use a sensitive and inclusive approach to collecting PHI that does not discriminate against or stigmatize the client.
- Use professional judgment to tailor PHI collection to each individual client and their Massage Therapy needs.
- Ask clarifying questions throughout the session when appropriate to provide safe and effective Massage Therapy care.
- Explain the reasons for collecting PHI when the client asks.
In order to understand the client’s unique needs, views, preferences, and concerns when collecting PHI, the RMT/MT must ask for:
- The client’s name, contact information, and emergency contact details;
- Name and address of primary physician and referring practitioners, if any;
- Date of birth and/or age, language preferences, and accessibility/mobility needs;
- History of Massage Therapy care;
- Updates or changes to PHI since the client’s last appointment (for subsequent visits);
- Information that is necessary to address an acute health concern requiring first aid, and/or referral for immediate or emergency care;
- Reason for seeking Massage Therapy care; and
- Allergies.
The RMT/MT must never ask the client about the following:
The RMT/MT must use professional judgment when collecting PHI to ensure the client receives Massage Therapy care that is safe for and tailored to their individual circumstances and specific needs. The RMT/MT may consider asking the client about their personal preferences, health conditions, symptoms and medications including, but not limited to, the following:
- Stage of life, e.g.:
- Pregnancy;
- Infancy and childhood;
- Adolescence;
- Adulthood;
- Senior years; and/or
- End of life.
- Reproductive system conditions/disorders, e.g.:
- Uterine fibroids, endometriosis; and/or
- Details related to pregnancies, childbirths and children when clients are receiving concurrent treatment for perinatal or reproductive disorders.
- Gender identity and pronouns;
- Recent/current injuries (strains, etc.);
- Conditions/disorders relevant to Massage Therapy treatment, e.g.:
- Skin, muscle, joint, bone, pain;
- Inflammatory;
- Cardiovascular; and/or
- Respiratory.
- Increased sensitivity to pain or pressure;
- Unmanaged immune dysfunction;
- Cancer status, including if:
- A client voluntarily discloses that they have/have had cancer, and/or if they are receiving/have received chemotherapy or radiation treatment.
- When a client voluntarily reports that they are seeking treatment for physical symptoms related to a mental health condition/disorder, an RMT/MT should limit their questions to the client’s physical symptoms; and
- Symptoms resulting from acute injury, infection or illness:
- Bruising;
- Fever;
- Pain and/or swelling/inflammation;
- Dizziness;
- Generalized loss of muscle strength; and/or
- Increased blood pressure/heart rate (e.g., palpitations).
- Current use of the following types of medications:
- Analgesics (pain medications);
- Non-steroidal anti-inflammatory medications (NSAIDs);
- Corticosteroids;
- Muscle relaxants;
- Anti-coagulants (blood thinners);
- Medications to address respiratory, bronchial conditions/disorders (inhalers etc.);
- Medications, recreational drugs, or substances that affect the ability to sense/experience pain;
- Medications that affect sensation; and/or
- Medications to address cardiovascular/circulatory conditions/disorders (e.g., anti-hypertensives etc.).
Relevant Legislation and Regulations
Related Career-Span Competencies (CSCs)
- Act with professional integrity
- Communicate effectively
- Comply with legal requirements
- Function in a client-centred manner
- Apply the principles of sensitive practice
- Maintain comprehensive records
- Treat others respectfully
- Practice in a manner consistent with current developments in the profession
- Use an evidence-informed approach in an RMT’s/MT’s work
FAQs
The Standard of Practice for Collecting Personal Health Information (PHI) is a new client-centred requirement to ensure RMTs/MTs are respectful to clients’ needs and not over collecting personal health information (PHI). As healthcare professionals, RMTs/MTs need PHI to deliver quality tailored care, and this standard helps RMTs/MTs have open conversations with their clients about their health. It specifies the PHI RMTs/MTs must ask, must never ask, and may ask clients under certain circumstances to provide safe and effective Massage Therapy care.
The Standard will come into effect on November 1, 2025.
RMTs/MTs document PHI using the Standard and its resources. Documentation must align with the Standard’s client-centred care and PHI collection requirements. For instance, RMTs/MTs must be aware of prohibited topics (e.g., HIV/AIDS) and ensure their collection approach uses client-centred language.
RMTs/MTs may use electronic documentation (e.g., an electronic health history form), but must have alternative options to use when needed (e.g., verbal intake). No matter how an RMT decides to collect health information, it must be documented into the client’s health record.
RMTs/MTs should regularly review their documents and intake process for alignment with the Standard in order to avoid any potential complaints.
No, CMTO does not require RMTs/MTs to share their methods for documenting the collection of PHI.
No, CMTO will not be reviewing forms or other documentation methods, however, our Practice Specialists are happy to answer questions about the Standard itself.
The Standard does not mandate formatting specifically, however, RMTs/MTs should prioritize accessibility:
- Use clear headings, legible fonts, and high contrast colours.
- Offer large-print or digital formats for clients with visual impairments.
Yes, but all information still needs to be verified for accuracy (e.g., “Has anything changed since your last appointment?”) and document changes as required.
