Thai Massage Health History Questionnaire
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- Marcus Fisher
- 5 years ago
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1 Name: Date: Thai Massage Health History Questionnaire Mobile Work Home Birthday Address Emergency Contact Name Relationship number Occupation How did you find me? When was your last massage? Where? Are you presently taking any medication? Yes No Please Explain: Have you had a recent major surgical procedure or injury? Yes No Please Explain: Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue? Yes No Please Explain: Please circle your stress level: Low High What do you hope to have addressed by visiting a Thai Massage practitioner?
2 Circle the following conditions that apply to you, past and present. Please add your comments to clarify the condition. Musculo-Skeletal Digestive Skin Headaches Indigestion Rashes Joint stiffness/swelling Constipation Allergies Spasms/cramps Intestinal gas/ bloating Broken/Fractured bones Diarrhea Acne Strains/Sprains Irritable bowel syndrome Athlete s foot Impetigo Back, hip pain Crohn s Disease Hemophilia Shoulder, neck, arm, hand pain Colitis Other Leg, foot pain Other: Chest, ribs, abdominal pain Problems walking Nervous System Loss of Appetite Jaw pain/tmj Depression Tendonitis Difficulty concentrating Bursitis Numbness/tingling Hearing Impaired Arthritis Fatigue Visually Impaired Osteoporosis Sleep disorders Diabetes Scoliosis Ulcers Fibromyalgia Other: Paralysis Post/Polio Syndrome Circulator/Respiratory High blood pressure Herpes/shingles Cerebral Palsy Cancer Tuberculosis Low blood pressure Epilepsy Other: Dizziness Shortness of breath Fainting Cold feet or hands Cold sweats Stroke Heart condition Chronic Fatigue Syndrome Multiple Sclerosis Muscular Dystrophy Parkinson s Disease Other: Reproductive System Allergies Asthma Other: mo. Pregnancy
3 I understand that a massage Therapist does not diagnose disease, illness, or prescribe any treatment or drugs, nor do they provide spinal manipulation. I understand that draping will be used at all times (if applicable) and that breast massage will not be administered on female clients. I understand that if I become uncomfortable for any reason that I may ask the Therapist to end the massage session, and they will end the session. I understand that the massage Therapist may end the session for any inappropriate behavior. I have stated all of the conditions that I am aware of, and this information is true and accurate. I will inform the therapist of any changes in my status. Client s signature Consent for Therapy and Waiver of Liability The undersigned ( Client ) hereby freely consents to receipt of massage services from: CATA NYC Thai Massage Clinic. Client agrees as follows: Client understands and agrees that they will provide the Therapist with complete and accurate health information, and a written referral from Client s primary healthcare provider if Client is currently receiving care or has a specific medical condition or symptoms for which Client takes medication or receives periodic evaluations or treatment. Client understands that massage therapy is designed to be an ancillary health aid and is not suitable for primary medical treatment for any condition. 1. Client and Therapist will discuss the potential benefits and possible side effects of massage therapy and agree upon a course of focused attention and manual therapy for the predetermined goals of stress reduction, relief of muscular discomfort, and/or promotion of general health. Client has been given an opportunity to ask questions of the Therapist and has received all requested information. 2. Client understands that the unclothed body will be draped at all times for warmth, sense of security, and as a mark of massage therapy professionalism. Client agrees to immediately inform the Therapist of any unusual sensation or discomfort so that the application of pressure may be adjusted to Client s level of comfort. Client understands that massage therapy is not sexual in any manner and that any illicit or suggestive remarks or behavior on the client s part will result in an immediate termination of the therapy session. Client understands that if the session is terminated for such reason, payment will be expected in full; regardless if the massage is completed or not. 3. Client hereby assumes full responsibility for receipt of the massage therapy, and releases and discharges Therapist from any and all claims, liabilities, damages, actions, or causes of action arising from the therapy received hereunder, including, without limitation, any damages arising from acts of active or passive negligence on the part of the Therapist, to the fullest extent allowed by law. 4. Client, in signing this consent for Therapy and Waiver of Liability ( Consent ), understands and agrees that this Consent will apply to and govern the current and all future therapy sessions performed by Therapist Client Signature Client Printed Name Date Massage Therapist Signature Massage Therapist Printed Name Date
4 Date Client Remarks Therapist Remarks Session Length Notes
5 Release Form for Media Recording I hereby consent to the participation in interviews, the use of quotes, the taking of photographs and the making of audio only or audiovisual recordings of the individual named above by the Center for the Advancement of Therapeutic Arts, Inc. (CATA) for the Thai Massage Classes, Thai Massage clinic, and all Thai Massage events presented by CATA. I also grant to CATA the right to edit, use, re-use, publish, re-publish, reproduce and distribute said products for non-profit purposes, including use in print, on the internet, and all other forms of media now known or hereinafter invented, in perpetuity. In addition, I agree that, as between CATA and me, the photographs and audio recordings, audiovisual recordings showing my image, including the copyrights therein, shall be the sole property of CATA. I also hereby release CATA and its agents and employees from all claims, demands, and liabilities whatsoever in connection with above uses. Please check one of the following choices: I GRANT permission for my name/photo/image and all other personal identifiers to be published on the public Internet site and any other form of print/electronic media and/or print/electronic outlet. I GRANT permission for my name only (no image) to be published in all media outlets as in the above. I GRANT permission for my image only (no name) to be published in all media outlets as in the above. I DO NOT GRANT permission for the use of my name/image in any print or electronic media, including the Internet.
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HEALTH HISTORY FORM How did you hear about our clinic? Yellow Pages Website Our sign Facebook Other? Family/Friend/Co-Worker WHO? Permission to acknowledge the person who referred you (Initials) Name:
CHIROPRACTIC NEW PATIENT FORM REASON FOR VISIT
FULL NAME: DATE OF BIRTH (DD/MM/YYYY): STREET ADDRESS: PROVINCE: HOME PHONE: (CHECK WHICH PREFERRED) WORK PHONE: EMAIL ADDRESS: NEW LEGISLATION REQUIRES THAT WE OBTAIN CONSENT PRIOR TO SENDING EMAILS TO
Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:
Patient Medical Information Name: First Middle Last Sex: M / F Age: Date of Birth: Social Security # Driver s License # Home Address: City: State: Zip Code: Home Phone: Occupation: Cell: Employer: Business
Rupp Chiropractic FAMILY PHYSICIAN FEMALES: ARE YOU PREGNANT, OR A CHANCE YOU MIGHT BE PREGNANT? YES / NO HOW WERE YOU REFERRED TO OUR OFFICE?
PATIENT INFORMATION NAME DATE ADDRESS CITY STATE ZIP HOME # CELL # WORK # E MAIL ADDRESS SOCIAL SECURITY # I WOULD LIKE TO RECEIVE EMAIL APPOINTMENT REMINDERS [YES] [NO] RACE: AMERICAN INDIAN ALASKA NATIVE
PATIENT MEDICAL HISTORY INTAKE FORM
Northgate Professional Center 1985 Main Street, Suite 209 Springfield, Massachusetts 01103 Tel; 413-455-1081 Fax; 413-391-7489 www.marimedconsults.com PATIENT MEDICAL HISTORY INTAKE FORM Patient Information:
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
Application for Patient
Application for Patient First Name: M.I.: Last Name: Date: Address: City: State: Zip: SS#: - - Age: DOB: / / Male / Female Email: Home #: Cell # Work # Primary Care Physician: Do we have permission to
1160 Suncast Ln El Dorado Hills, CA
1160 Suncast Ln El Dorado Hills, CA 95762 916.221.8534 PATIENT INFORMATION Name: Birth date: Parent/Guardian name (if patient is a minor): Address: Cell phone: Home Phone: Email: Emergency contact: Referring
Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon)
Name_ Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon) For reminders do you prefer Phone Calls, Text Messages or Emails? CALL ME / TEXT ME / EMAIL ME Email Address
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.