Cardiovascular Consent Form
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- Rudolf Anderson
- 5 years ago
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1 Cardiovascular Consent Form Dear Primary Care Provider, A patient currently under your care for a cardiovascular condition has come to the Kingsbury Club Therapy Center to receive a therapeutic massage. A concern was raised during your patient s medical history interview that needed further clarification. This sheet is intended to provide our therapists with more information needed to design the massage session most beneficial for your patient. Please read the accompanying information sheet and fill in the information requested below before signing. Client name: Cardiovascular condition(s) of concern: M.I. history Heart Murmur CHF Hypertension Stroke or TIA Primary condition: Any additional medical issues: Some massage techniques are thought to increase venous return from the extremities. Direct pressure is used on skeletal muscle, affecting superficial and deeper vascular structures. Please determine whether your patient is an appropriate candidate for receiving massage at Kingsbury Club by answering the following questions: Yes No 1. Does your patient have moderate to severe varies? Direct local massage pressure to affected areas may injure varicose veins or dislodge any thrombi. (Other sites may be massaged safely.) 2. Is there an elevated risk of thrombosis? Direct local pressure may dislodge any existing thrombi. Individuals with ANY current risk of thrombosis should not be seen at Kingsbury Club. For individuals with prior history of thrombosis, massage therapists avoid massage of affected limbs. 3. Is there an elevated risk of bruising or bleeding? Some deeper massage techniques may injure fragile tissue (but lighter strokes may be applied). 4. Has there been any history of edema present in the extremities? Our therapists are not trained to massage edematous tissue related to cardiovascular conditions, but can massage other areas. 5. Is your patient able to lie comfortably in the prone, supine or lateral lie positions? If any positions cause shortness of breath or other discomfort, they will be avoided during the massage. 6. Are any medical restrictions imposed on your patient s exercise activities? If aerobic activities are restricted, massage may need to be gentle to avoid accelerating venous return. 7. Are there any associated renal or pulmonary conditions? Circulatory massage is thought to increase venous return; non-circulatory techniques are used if renal function is compromised; positioning may need adjusting if pulmonary function is compromised. 8. Is the patient s blood pressure unstable, erratic, or poorly controlled? The Kingsbury Club massage setting is inappropriate for individuals with medically complex conditions. 9. Do you recommend that therapists avoid pressure on sites such as vascular structures such as the carotid or temporal arteries, due to risk or history of CVA? Massage therapists will avoid pressure on any areas where plaque or thrombi could be dislodged. Additional precautions or recommendations for massage: I have reviewed this patient s record and read the above cautions pertaining to massage. I approve this patient for massage sessions with the above restrictions. If I suggest any additional precautions or recommendations, I have listed them above. Signature Primary Care Practitioner Please print Primary Care Practitioner name
2 General Consent Form for Clients with Health Conditions Dear Physician: Your patient has come to the Kingsbury Club to receive a therapeutic massage. Sometimes modifications are necessary for a client to be massaged safely. Please help us clarify these issues and provide us with some guidance in seeing your patient by addressing the following concerns and approving massage therapy sessions for your patient. Type of massage strokes used: Medium and deep stroking, kneading and compression of the tissues Parts of the body included in the massage: A typical session could include strokes on the back, neck, shoulders and head. Hips and upper and lower extremities are also included. Occasionally massage is provided to the face and abdomen at client s request, if there are no contraindications at those sites. Health condition(s) of concern: Possible massage adjustments: Questions for client s physician: Please describe any additional concerns or precautions we should follow when providing massage to your patient:: My patient, named above, has my permission to receive massage at Kingsbury Club. I have reviewed this patient s record and have read through the common massage therapy adjustments above, and added any of my own concerns. I approve this patient for massage sessions with the above guidelines. Physician Signature Please print Physician s Name
3 Muscular Therapy Client Record Name Home Phone Work phone Address Occupation Male / Female Age Have you ever had a therapeutic massage before? Yes No Many Times What is the amount of tension in your life? (none) (average) (extreme) What physical activities do you do on a daily or weekly basis? What is your daily water intake? Please circle any painful or tense areas as well as regions that you tend to hold your stress: Head/face Low back Shoulders Neck Abdomen Legs/feet Arms/hands Mid-back Are you currently under a Physician s care? Yes / No For what condition? Do you take medication for this conditions? Yes / No List medications you take Do you take any medications or drugs that alter sensation? (e.g., pain medication, muscle relaxants, alcohol or other depressants or stimulants) These may affect the Therapist s choice of techniques Please check any of the following health issues that you have had in the past year: Allergies: Angina Anxiety Asthma Blood Clots Cancer Carpal Tunnel Syndrome Communicable Diseases Disc Problems Fibromyalgia Heart Disease Hepatitis Herpes Simplex Hospitalization Hypertension Immune System Conditions Irritable Bowel Syndrome Insomnia Migraines/Headaches Phlebitis/Thrombosis Pregnancy Repetitive Strain Injuries Sciatica Stroke Surgery Varicose Veins Whiplash CLIENTS: PLEASE CONTINUE TO OTHER SIDE For therapist use (List client preferences, supports, positioning, table height, etc.):
4 GENERAL MEDICAL SIGNS AND SYMPTOMS: Please indicate if you currently have any of the following conditions: Symptom Yes No Location: Please describe 1. Any areas of infection? 2. Any areas of swelling, 2. edema or tendency to swell? 3. Any areas of numbness or 3. altered sensation? 4. Any areas of pain? SPECIFIC MEDICAL CONDITIONS: For your safety our therapists must be aware of all medical conditions. Therapeutic massage may affect these and your health. Condition Yes No Please describe 5. Arthritis: 6. Cancer or Tumors: 7. Cardiovascular Diseases: Please circle all that apply: Anemia, Angina, Arteriosclerosis, Congestive Heart Failure, Heart Attack, Heart Murmur, Hemophilia, Hypertension, Varicose or Spider Veins, Phlebitis, Blood Clots, Deep Vein Thrombosis, any inflamed blood vessels 8. Diabetes: 9. Injuries: 10. Kidney, Liver or Urinary problems: 11. Respiratory Conditions: 12. Skin Conditions: P lease circle all that apply: Acne, Abrasions/Cuts, Birthmarks/Moles, Bruises, Dermatitis, Eczema, Herpes, Hives, Poison Ivy/Oak/Sumac, Psoriasis, Skin Tags, Sunburns, Warts 13. Surgery: of Surgery: Describe: 14. Gastrointestinal Problems: Other Medical Conditions not mentioned above: Please describe: Please read and sign: I verify that all information provided is correct and current to the best of my knowledge. I understand that any information provided by the Therapist is not prescriptive or diagnostic in nature. I hereby give my consent to receive therapeutic massage at the Kingsbury Club and will not hold the Kingsbury Club or therapist responsible for any personal injury or loss of property. Signature
5 Name MT Indicate areas of discomfort with a X on the diagram below: I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I forget to do so. It is also understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Client Signature Practitioner Signature Consent to Treatment of Minor: By my signature below, I hereby authorize to administer massage, bodywork, or somatic therapy techniques to my child or dependent, as they deem necessary. Age of Child Signature of Parent or Guardian
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CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
Name: Date: Address: City: State: Zip: Birthday: / /
PERSONAL TRAINING Name: Date: Address: City: State: Zip: Birthday: / / Sex: Male Female Name of Gym: Occupation: Phone (home): Phone (work): Body Weight: Body Fat: Height: Personal Goals 1. Primary Training
Who may we thank for referring you?
NEW PRACTICE MEMBER APPLICATION Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Social Security #: Email: Occupation Employer s Name Status: Single / Married / Divorced /
Birth Date Age Social Security # Marital Status (circle) Have you had chiropractic care in the past? Yes No If yes, how long ago?
136 Wilson Pike Circle Brentwood, TN 37027 NEW PATIENT INFORMATION Please complete ALL questions below unless otherwise indicated. First Name Last Name Date Street Address City State Zip Cell Phone Provider
NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW- UP NEUROLOGY QUESTIONNAIRE
Neurology East 48 Medical Park Dr. East Richard G. Diethelm, MD Suite 351 Andrea Sutton, RN, MSN, ANP- BC Birmingham, AL 35235 (205) 836-9366 www.neurologyeast.com NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW-
New Patient Intake Form. Patient s Full Name. Male Female Age: Date of Birth: / / Mailing Address: City: State: Zip:
New Patient Intake Form Date: / / Patient s Full Name E-Mail: Home Phone: Cell: Male Female Age: Date of Birth: / / Social Security # - - Mailing Address: City: State: Zip: Married Single Widowed Separated
Home Address. City Postal Code Home Telephone # Business Telephone # Address. Emergency Contact Name, Address, Phone#
Date Name / / last first middle initial Personal Health # - Male Female Home Address City Postal Code Home Telephone # Business Telephone # Cell # E-Mail Address Best way to contact you: Home # Work #
New Practice Member Application
New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Social Security #: Email: Occupation Employer s Name Status: Single / Married / Divorced /
New Patient Intake Form
New Patient Intake Form Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name _ Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
HEALTH QUESTIONNAIRE
HEALTH QUESTIONNAIRE NAME AGE SEX: Male / Female DATE COMPLETED: OCCUPATION EMPLOYER HEIGHT WEIGHT BIRTHDATE DOMINANT HAND: Left / Right NAME OF YOUR PRIMARY CARE PHYSICIAN (INTERNIST OR PEDIATRICIAN):
Naturopathic & Acupuncture Intake Form (Age 14+)
Dr. Katie Thomson Aitken BAS, ND Dr. Alaina Gair, B.Sc., ND 86 Norfolk St., Guelph 519-827-0040 Contact Information Naturopathic & Acupuncture Intake Form (Age 14+) Name: Gender: Age: Birth Date (dd/mm/yy):
Patient Registration Form
Patient Registration Form Name: Today s Date: FIRST MIDDLE LAST Home Address: City: State: Zip: Telephone: ( ) Birthdate: Age: Occupation: SSN: Employer: Years There: Employer s Address: City: State: Zip:
Please mark the severity of your pain on the following line: On your worst days with a W On your average days with an A On your best days with a B
Today s Date: NEUROSURGERY Name: (Last) (First) (MI) Age: Birth Date: Female Male Dominant hand: Right Left Pharmacy- Name: Phone: Location: What are you being seen for today? Location of pain (indicate
Welcome to Medina Family Chiropractic and Acupuncture!
Welcome to Medina Family Chiropractic and Acupuncture! Please fill out this form and return it to the front desk. Let us know if you have any questions! Personal information Date: First name: Middle name:
Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Home # Cell # Work #
Patient Information: Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Email: Home # Cell # Work # Text Appointment Reminders: Yes No