Massage Client Intake Form
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- Silvester Pearson
- 5 years ago
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1 Massage Client Intake Form Date: Name: Male Female DOB: Address: City: State: Zip: Phone: Can a message be left at this number? Yes No Occupation: Hobbies/Sports/Most frequent activities: What is the goal of your visit? (Example: Reduce pain, Reduce stress, etc.) Have you ever experienced a professional massage/bodywork session? Yes No Are you a patient at Freedom Chiropractic? Yes No Did another doctor refer you for massage? Yes No If Yes, who? (We ll need a copy of the referral) If No, how did you hear about me?
2 GENERAL & MEDICAL HISTORY Are you currently under the care of a health practitioner (including chiropractor) for any reason? Y / N If yes, please explain: If on medication, please list and explain: Please check any that apply & explain: Allergies Herniated/bulging disc Arthritis High/Low Blood Pressure (Circle one) Blood clots Immune system disease Blood or lymph disease Infection Cancer Influenza Cardiac problems Open cuts or sores Diabetes Pregnant (How far along? ) Fever Seizures Fractures or Injuries Skin conditions Headaches/Migraines Surgeries Do you have any other conditions? If so, please explain. Do you have sensitivity to fragrances? If so, which ones?
3 Please indicate current problem areas in your body by marking letters from the key on the diagrams below. Key: P N S I Areas of pain and/or tenderness Areas of numbness and/or tingling Stiff joints and/or muscle stiffness Scars, past surgeries, bruises and/or wounds OFFICE USE ONLY: Client Preferences: Pressure: Light Medium Firm
4 Massage Therapy Informed Consent I understand massage therapy provided by Jennifer Weisser is intended to enhance relaxation, reduce pain caused by muscle tension, increase range of motion, improve circulation and offer a positive experience of touch. If any pain or discomfort is experienced, I will immediately inform the massage therapist so that the pressure can be adjusted. I understand that massage therapy is not a substitute for medical treatment or medications, and that it is recommended that I concurrently work with my Primary Caregiver for any condition I may have. I am aware that the massage therapist does not diagnose illness or disease, does not prescribe medications, and that spinal manipulations are not part of massage therapy. I have informed the massage therapist of all my known physical conditions, medical conditions and medications, and I will keep the massage therapist updated on any changes. Massage therapy/bodywork should not be performed if I have certain medical conditions; therefore, I affirm that I have stated all known medical conditions and answered all questions honestly. Client s Printed Name Client s Signature Date I hereby acknowledge receipt of the Client Bill of Rights and understand my rights as a client. Client s Signature Date
5 Complementary and Alternative Health Care (Client Bill of Rights) Your Massage Therapist, Jennifer Weisser, received training in massage from Globe University in Moorhead, MN. She has received her state licensure in November 2015 and is a member of ABMP. THE STATE OF NORTH DAKOTA HAS NOT ADOPTED ANY EDUCATIONAL AND TRAINING STANDARDS FOR UNLICENSED COMPLEMENTARY AND ALTERNATIVE HEALTH CARE PRACTITIONERS. THIS STATEMENT OF CREDENTIALS IS FOR INFORMATIONAL PURPOSES ONLY. UNDER NORTH DAKOTA LAW, AN UNLICENSED COMPLEMENTARY AND ALTERNATIVE HEALTH CARE PRACTITIONER MAY NOT PROVIDE A MEDICAL DIAGNOSIS OR RECOMMEND DISCONTINUANCE OF MEDICALLY PRESCRIBED TREATMENTS. IF A CLIENT DESIRES A DIAGNOSIS FROM A LICENSED PHYSICIAN, CHIROPRACTOR, OR ACUPUNCTURE PRACTITIONER, OR SERVICES FROM A PHYSICIAN, CHIROPRACTOR, NURSE, OSTEOPATH, PHYSICAL THERAPIST, DIETITIAN, NUTRITIONIST, ACUPUNCTURE PRACTITIONER, ATHLETIC TRAINER, OR ANY OTHER TYPE OF HEALTH CARE PROVIDER, THE CLIENT MAY SEEK SUCH SERVICES AT ANY TIME. Massage is a specific manipulation of soft tissue to decrease muscle tension and pain, increase range of motion and circulation, and reduce stress; all which promotes a healthy and balance well being. As a client, you have a right to a reasonable notice of changes in services or charges, which will be posted at the front desk. Fees are due at the completion of each visit cash or checks made payable to Freedom Chiropractic Health Center. Will bill insurance for massage specifically for Motor Vehicle Accident; all other insurances or situations are clients responsibility. You have the right to complete and current information concerning the practitioner s assessment and recommended service that is to be provided, including the expected duration of the services to be provided. Your records and transactions with the practitioner are confidential, unless release of these records is authorized in writing by you, the client, or otherwise mandated by law. You are allowed access to your records as provided for in accordance with North Dakota Statutes. As a client, you have the right to choose freely among available practitioners and to change practitioners at any time. You have the right to a coordinated transfer when there will be a change in the provider of services. You have the right to search for other services in the community and your practitioner will help you find that information. You have the right to refuse services or treatment, unless otherwise provided by law and you may assert these rights without retaliation. You may expect courteous treatment and to be free from verbal, physical, or sexual abuse by the practitioner. You have the right to refuse treatments or services at any time during a massage session. If you have a complaint, it may be directed to Jake Schmitz, DC and owner of Freedom Chiropractic Health Center. Phone number
Complementary and Alternative Health Care Client Bill of Rights for Senior Citizens (60+) The State of Minnesota has not adopted any educational
Complementary and Alternative Health Care Client Bill of Rights for Senior Citizens (60+) 1) Practitioner s name: Jennifer N. Bierma CMT Title: Certified Massage Therapist/Owner of No Knots Professional
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THE STATEOF MINNESOTA HAS NOT ADOPTED ANY EDUCATIONAL TRAINING STANDARDS FOR UNLICENSED COMPLEMENTARY AND ALTERNATIVE HEALTH CARE PRACTITIONERS
COMPLEMENTARY AND ALTERNATIVE HEALTH CARE BILL OF RIGHTS Please read and sign this complementary and alternative health care bill of rights. I am providing you with this Client Bill of Rights in accordance
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Somerset Hills Physical Therapy, PC 180 Mount Airy Road, Suite 103 Basking Ridge, NJ 07920 Phone (908) 766-1407 Fax (908) 953-8454 wwwsomersethillsptcom Patient Information: Name Sex M F Date of Birth
WELCOME TO THE BURLINGTON NATURAL HEALTH CENTRE PLEASE FILL IN THESE FORMS AS COMPLETELY AS POSSIBLE. THANKYOU!
WELCOME TO THE BURLINGTON NATURAL HEALTH CENTRE PLEASE FILL IN THESE FORMS AS COMPLETELY AS POSSIBLE. THANKYOU! NAME DATE ADDRESS Gender CITY, PROVINCE HOME PHONE E MAIL POSTAL CODE DATE OF BIRTH (D/M/Y)
Health and History Assessment ACCOUNT #: HIPPA: CTT:
ACTION Chiropractor LLC Health and History Assessment ACCOUNT #: HIPPA: CTT: NAME: SEX: M/ F BIRTHDATE: / / ADDRESS: CITY: STATE: Zip: PHONE # s: HOME: ( ) WORK: ( ) CELL: ( ) HEIGHT: WEIGHT: MARITAL STATUS:
PERSONAL INFORMATION. Date of Birth Age (Last) (First) (M.I.) Address City/State Zip. Phone # Home Work Cell
*If the reason for your visit is due to a worker s compensation injury or an automobile accident, please inform the front desk immediately. PERSONAL INFORMATION of Birth Age (Last) (First) (M.I.) Address
ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
NAME: ABOUT YOU WHO REFERRED YOU TO OUR OFFICE? CHIROPRACTIC EXPERIENCE ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: CELL PHONE: How did you hear about our office? NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT