Recuperate Massage Intake Form
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- Daniella Houston
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1 Recuperate Massage Intake Form Name Phone ( ) DOB Address City State Zip Referred by/how did you hear about R.M : Phone ( ) Emergency Contact: Phone ( ) Occupation ( ) Male ( ) Female Physician Health Insurance carrier Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to service being provided. Have you ever experienced a professional massage or bodywork session? ( ) Yes ( ) No Where If yes, how often do you receive massage therapy? What are your massage or bodywork goals? Do you have any difficulty lying on your front, back, or side? ( ) Yes ( ) No If yes, please explain Do you have any allergies to oils, lotions, or ointments? ( ) Yes ( ) No If yes, please explain Do you have sensitive skin? ( ) Yes ( ) No What kind of pressure do you prefer? ( ) light ( ) medium ( ) firm ( ) deep Are you wearing contact lenses ( ) dentures ( ) hearing aid ( ) hair piece ( )? Do you have numbness or stabbing pains? ( ) Yes ( ) No If yes explain Do you sit for long hours at a workstation, computer, or driving? ( ) Yes ( ) No If yes, please describe Do you perform any repetitive movement in your work, sports, or hobby? ( ) Yes ( ) No If yes, please describe Do you experience stress in your work, family, or other aspect of life? ( ) Yes ( ) No If yes how do you think it has affected your health? muscle tension ( ) anxiety ( ) insomnia ( ) irritability ( ) others Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort? ( ) Yes ( ) No If yes identify
2 Circle any specific areas you would like concentration on during session: Medical History In order to plan a massage session that is safe and effective, I need some general information about your medical history. Are you currently under medical supervision? ( ) Yes ( ) No If yes, please explain Do you see a chiropractor? ( ) Yes ( ) No If yes, how often? Are you currently taking any medication? ( ) Yes ( ) No If yes, please list Have you ever had any broken bones, injuries or surgeries? ( ) Yes ( ) No If yes, explain Please check any condition listed below that applies to you: ( ) contagious diseases/ skin condition ( ) phlebitis ( ) open sores or wounds ( ) deep vein thrombosis/blood clots ( ) easy bruising ( ) joint disorder/rheumatoid arthritis/osteoarthritis/tendonitis ( ) recent accident or injury ( ) osteoporosis ( ) recent fracture ( ) epilepsy/seizures ( ) recent surgery ( ) headaches/migraines ( ) artificial joint ( ) cancer ( ) sprains/strains ( ) diabetes ( ) current fever ( ) decreased sensation ( ) swollen glands ( ) back/neck problems ( ) allergies/sensitivity ( ) fibromyalgia ( ) heart condition ( ) TMJ ( ) high or low blood pressure ( ) carpal tunnel syndrome ( ) circulatory disorder ( ) tennis elbow ( ) varicose veins ( ) pregnancy if yes how many month? ( ) atherosclerosis Please explain any condition that you have marked above Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you?
3 Client Consultation Form Please take a moment to read all of the following statements and print and sign your name in agreement to statements below: A. I, the therapist anticipate on using the following type of massage therapy services/techniques upon agreement/ preference: Swedish Massage, Deep Tissue, Trigger Point, Prenatal, Hot Stone, Myofascial Release, Neuromuscular Therapy, Facial Massage, and Foot Massage/Scrub. B. The indications for massage are stress, headaches, pain in muscles, muscular spasms, pain in joints, pain in shoulders, hands, arms, or legs and feet. C. The contraindications for massage are fever, acute infectious disease, inflammation, osteoporosis, varicose veins, blood clots, edema, high blood pressure, diabetes, cancer, intoxication, skin problems, hernia, and some diseases (please discuss your health with me if you have any of these conditions or others.) D. The areas of the body that will be massaged during the session upon agreement/preference will be: back, neck, shoulders, glutes, legs, feet, arms, hands, stomach, face, chest, and head. Intimate areas and breasts will be avoided. E. I understand that any illicit or sexually suggestive remarks or advances that I make will result in immediate termination of the session, and I will be liable for payment of scheduled appointment. F. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions/injuries and answered all question 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 fail to do so. G. By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork. H. I understand that the massage/bodywork I receive is provided for basic purpose of relaxation, stress reduction, and relief of muscular tension or spasm and increase in circulation. If I experience any pain or discomfort during session, I will immediately inform my therapist so pressure/strokes may be adjusted to my level of comfort. I understand that I may feel some discomfort during deep tissue massage and some soreness or 1-3 days after. I will not hold my therapist responsible for pain or discomfort I experience during or after session. I. I further understand that massage or body work should not be construed as 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 of which I am aware. I understand that massage/ bodywork practitioners are not qualified to perform spinal or skeletal adjustments,
4 diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of session given should be construed as such. J. If for any reason you feel uncomfortable during the massage, you may ask me to cease the massage, and I will end the session immediately. K. Draping will be used at all times during the session, only the area of the body that is being massaged will be uncovered. L. Prenatal massage clients must be in their second to third trimester to receive a massage and have their doctor ok them for a prenatal session in writing. Ensuring the therapist that the client doesn t have the following conditions: high risk pregnancy, pregnancy induced hypertension (PHI), preeclampsia, and previous pre term labor. Clients, who just had a baby, may come in for a session six weeks after having baby. M. Clients under the age of 17 must be accompanied by parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under 17 to receive massage with or without parent/guardian present in session room. N. If a cancelation is necessary, appointments must be canceled at least 24 hours in advance, otherwise a payment of $39.99 for missed appointment will be expected before the next appointment. Information and Suggestions Prior to your massage, please remove contact lenses if needed and all jewelry. Pull long hair back with clip or band. In general, massage is given while you are unclothed. However, you may choose to wear undergarments. You will be covered with top sheet throughout your session; only areas being massage will be uncovered. This is your massage and you should be as comfortable as possible. Please make sure to breathe slowly in and out throughout your session and relax your body. Feel free to ask any questions before, during, or after the session. I have received the policy statements, and have read and agreed to the policies therein. Client Name Print: Date: Client Signature: Date: Therapist Signature: Date:
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DOCTOR REFERRAL LETTER Dear Living Longer Living Stronger Program Co-ordinator, I am recommending my patient/client undertake a monitored Living Longer Living Stronger strength training program that incorporates
Date: Can we leave messages on voice mail at home/work/cell? Yes No. Sex: Male Female SS#: If yes, what type? Auto Work Other.
1 Patient Information : Name: Last First MI Email address: Mailing Address: Phone # (H) (W) (Other) Can we call you at work? Yes No of Birth: Can we leave messages on voice mail at home/work/cell? Yes
Which physician are you scheduled to see? Scheduled Appointment Date: As a reminder: Please arrive minutes prior to your scheduled appointment.
Which physician are you scheduled to see? Scheduled Appointment : As a reminder: Please arrive 15-20 minutes prior to your scheduled appointment. Please bring the following on the day of your scheduled
Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.
CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
Practice Member Profile
Practice Member Profile Please print Name: : Phone number: (H) (C) Cell provider: Address: City: State: Zip: of Birth: Age: Male Female (circle one) Marital Status: Name of Spouse: Number of Children:
(emergency room pain)
Welcome to Moving Body Chiropractic! We re glad you re here. Whether you re looking to work on a specific problem or just feel great, this form is the start to your wellness journey! Please take the time
Welcome to our clinic! NEW PATIENT HEALTH QUESTIONNAIRE
Welcome to our clinic! NEW PATIENT HEALTH QUESTIONNAIRE First Name: Last Name: Date of Birth (mm/dd/yyyy): / / Gender: Male Female Current Occupation: Address: Appt no. Postal Code: Home Phone ( ) - Work
New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH p: f:
New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH 03049 p: 603.465.2235 f: 603.465.2236 About You Last Name: First Name: Middle Initial: Nickname: Date of Birth: Age: Gender: [ ] M [ ] F
Who is filling out this intake form? Self Spouse Parent Guardian
Office Use Only: Reviewed with Patient Data Entry Scan & File Date: Date: Date: Initials: Initials: Initials: Today s Date: Who is filling out this intake form? Self Spouse Parent Guardian If you are not
**PLEASE NOTE OUR NEW ADDRESS** The Spine Center 159 Wells Ave, Newton, MA Ph: Fax:
Helpful Telephone Numbers Pre-Registration 855-890-9241 Hospital Billing (NWH) 617-726-3884 Physician/Provider Billing (MGPO) 617-726-3884 Web Address nwh.org Pre-Registration Please call up to 7 days
Patient First Name: Last Name: Street Address: City: State: Zip Code. Mobile Phone: Home Phone: Work Phone:
Dr. Beth Kozak Welcome! New Patient Information Form Please provide us with the following information: Patient First Name: Last Name: Street Address: City: State: Zip Code Mobile Phone: Home Phone: Work
Revelation Chiropractic Health Profile
Revelation Chiropractic Health Profile Name Date / Age Male / Female Address Apt City Zip Phone Numbers: Home Cell Circle best number to reach you at: Home Cell Date of Birth / / Occupation Email Address
Pain Relief Recover from Injury Chiropractic Therapeutic Laser Therapy. Release & Balance Method Nutritional Counseling Laboratory Testing & Analysis
Health Solutions Center John Gangemi Chiropractic Physician Date Date of Birth Name Mailing Address Home Phone Cell Occupation Email How Did You Hear About Our Office Whom May We Thank For Referring You
NPM INTAKE FORM. Home Phone No.: Work Phone No.: Cell Phone:
NPM INTAKE FORM INFORMATION: Name: Chosen Name (What would you like to be called?): Address: Date: Age: City/State/Zip: Home Phone No.: Work Phone No.: Cell Phone: Email Address: Date of Birth: Occupation: