Corner on Wellness Chiropractic Center Therapeutic Massage

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Corner on Wellness Chiropractic Center Therapeutic Massage Patient Name Date Address _ City State Zip Phone Email Emergency Contact Name Phone Employer Work Phone Date of Birth Social Security # Is condition due to an injury? No Yes If yes: Auto Accident L& I Other Date of Injury Do you have a claim currently open? Yes No Name of Referring Physician Phone L & I INSURANCE INFORMATION (Required if you have been injured on the job) Insurance Company Claim Number Claims Adjuster Phone AUTO INSURANCE INFORMATION (You may skip this section if you have not been in an auto accident) Do you have Personal Injury Protection on your insurance policy? Yes No Insurance Claim Number Name of Your Insurance Company Address _ City State Zip Claims adjuster Phone ATTORNEY INFORMATION (If applicable) Name of Attorney Phone Address _ City State Zip

PLEASE READ CAREFULLY AND SIGN The information I have provided is complete and accurate to the best of my knowledge and I understand that I am responsible for informing Corner on Wellness Chiropractic Center of any changes in my health condition, or any changes in the information as presented on this form. I agree to the release of information for medical and/or insurance purposes, and I authorize Corner on Wellness Chiropractic Center to obtain any information from my primary healthcare providers, my attorney and/or my insurance carrier concerning my health, my insurance claim and any legal proceedings as they relate to my treatment. I clearly understand that massage therapy treatments are my personal financial responsibility; if for any reason payment is denied either by my insurance company or by my attorney, I will make arrangements with Corner on Wellness Chiropractic Center to pay for the massage treatments I have received. I further understand that I may be charged for appointments cancelled with less than 24 hours notice. Patient Signature Date Parent or Guardian Signature Date (If patient is a minor, signature of parent or guardian is required)

WELCOME TO CORNER ON WELLNESS CHIROPRACTIC CENTER You have made an appointment at Corner on Wellness Chiropractic Center for massage. Your therapist is a professional health care provider who will work with you and your physician to help you achieve your health care goals. Your first appointment with your therapist may last up to 1 hour, due to the time it takes to accomplish the initial assessment of your injuries or condition, and to determine a treatment plan which best suits your needs. Subsequent therapy sessions will be approximately one hour. Please keep in mind that your Therapist has reserved this time exclusively for you and will not treat any other patients during this time period. If you find that you will not be able to keep your appointment, please do us the courtesy of calling to inform us so that we may offer the time slot to another patient. Appointments cancelled with less than 24 hours notice will be subject to a $40 fee. Ii I have read the above statement and I understand that I am responsible for paying I have read the above statement and I understand that I am responsible for paying to to Corner on Wellness Chiropractic Center a $40 fee for any appointment missed Corner On Wellness Chiropractic Center a $40 fee for any appointment missed without at without at least 24 hours notice. least 24 hours prior notice. Signature: Date: Signature: Date:

MASSAGE PATIENT INTAKE Name Date Occupation Have you received massage before? Accidents, Injuries, or Surgeries: More than 5 years ago: Less than 5 years ago: Are you currently receiving medical or chiropractic care? Yes No If yes, please explain: Are you currently taking any medication or homeopathics? Yes No If Yes, please explain: Have you ever experienced any of the following conditions? AIDS Epilepsy Seizures Skin Allergies Allergies Fibromyalgia Stress Anemia Headaches Stroke Arthritis Heart Ailments Swollen Feet/Legs Back Pain Hemophilia Tendonitis Broken Bones Herpes Virus Thoracic Outlet Syndrome Bursitis High Blood Pressure Tingling Cancer Insomnia TMJ Dysfunction Chronic Fatigue Syndrome Low Blood Pressure Varicose Veins Circulation Problems Migraine Headaches Whiplash Colitis Muscle Spasms Constipation Numbness Diarrhea Phlebitis For Women Only: Diabetes Psoriasis Excessive Bleeding Digestive Problems Rashes Lack of Periods Disk Problems Ringworm Menstrual Cramps Diverticulitis Sciatica PMS

Are you currently experiencing any of the following conditions? Pregnancy Flu or Cold Infection Inflammation Contagious Disease Fever Comments: Substance Use: Alcohol Y N Tobacco Y N Other Any diet restrictions or regimens? Please describe: Sleep difficulties? Please describe: Do you wear contact lenses? Y N Regular physical activity: What kind? Where do you tend to hold stress in your body? Do you have any especially tender to touch areas? Why have you come for massage? Do you have any allergies to lotions or oils? During your massage do you like to carry on a conversation?

PERSONAL STATUS REPORT Name: Date: Identify CURRENT symptomatic areas in your body by drawing the symbols on the figures below. Key: Circle areas of pain X X over areas of joint and muscle stiffness /// Mark lines along the areas of numbness or tingling +++ Mark plus signs on scars, bruises or open wounds Additional Comments:

BACK PAIN AND DISABILITY QUESTIONNAIRE (revised Oswestry) Name: Date: This questionnaire has been designed to give the health care provider information as to how your back pain has affected your ability to manage everyday life. Please answer every section and mark in each section only the ONE box which applies to you. We realize that you may consider that two of the statements in anyone section relate to you, but please just mark the box which most closely describes your problem today. SECTION 1 PAIN INTENSITY The pain comes and goes and is very mild The pain is mild and does not vary much The pain comes and goes and is moderate The pain is moderate and does not vary much The pain comes and goes and is very severe The pain is severe and does not very much. SECTION 6 STANDING I can stand as long as I want without pain I have some pain on standing but it does not increase with time. I cannot stand for longer than one hour without increasing pain. I cannot stand for longer than ½ hour without increasing pain. I cannot stand for longer than 10 minutes without increasing pain. I avoid standing because it increases the pain straight away. SECTION 2 PERSONAL CARE SECTION 7 SLEEPING I would not have to change my way of washing or dressing I get no pain in bed. in order to avoid pain. I get pain in bed but it does not prevent me from sleeping well. I do not normally change my way of washing and dressing Because of pain my normal night s sleep is reduced by less than ¼. even though it causes some pain. Because of pain my normal night s sleep is reduced by less than ½. Washing and dressing increase the pain but I manage not Because of pain my normal night s sleep is reduced by less than ¾. to change my way of doing it. Pain prevents me from sleeping at all. Washing and dressing increase the pain and I find it necessary to change my way of doing it. SECTION 8 SOCIAL LIFE Because of the pain I am unable to do some washing My social life is normal and gives me no pain. and dressing. My social life is normal but increased the degree of pain. Because of the pain I am unable to do any washing and Pain has no significant effect on my social life apart from more dressing without help. interests, e.g. dancing, etc. Pain has restricted my social life and I do not go out very often. SECTION 3 LIFTING Pain has restricted my social life to my home. I can lift heavy weights without extra pain. I have hardly any social life because of the pain. I can lift heavy weights but it causes extra pain. Pain prevents me from lifting heavy weights off the floor. SECTION 9 - TRAVELLING Pain prevents me from lifting heavy weights off the floor, I get no pain whilst traveling. but I manage if they are conveniently positioned. I get some pain whilst traveling but none of my usual forms of travel make I can only lift very light weights at the most. any worse. I get extra pain whilst traveling but it does not compel me to seek alternate SECTION 4 - WALKING forms of travel. I have no pain on walking. I get extra pain whilst traveling which compels me to seek alternate forms of I have some pain on walking but it does not increase with travel. distance. Pain restricts all forms of travel. I cannot walk more than 1 mile without increasing pain. Pain prevents all forms of travel except that done lying down. I cannot walk more than ½ mile without increasing pain. I cannot walk more than ¼ mile without increasing pain. SECTION 10 CHANGING DEGREE OF PAIN I cannot walk without increasing pain. My pain is rapidly getting better My pain fluctuates but overall is definitely getting better. SECTION 5 SITTING My pain seems to be getting better but improvement is slow at present. I can sit in any chair for as long as I like. My pain is neither getting better or worse. I can only sit in my favorite chair as long as I like. My pain is gradually worsening. Pain prevents me from sitting more than 1 hour. My pain is rapidly worsening. Pain prevents me from sitting more than ½ hour. Pain prevents me from sitting more than 10 minutes. I avoid sitting because it increases my pain straight away.

NECK PAIN AND DISABILITY QUESTIONNAIRE (Vernon-Mior) Name: Date: This questionnaire has been designed to give the health care provider information as to how your back pain has affected your ability to manage everyday life. Please answer every section and mark in each section only the ONE box which applies to you. We realize that you may consider that two of the statements in anyone section relate to you, but please just mark the box which most closely describes your problem today. SECTION 1 PAIN INTENSITY I have no pain at the moment. The pain is very mild at the moment. The pain is moderate at the moment. The pain is fairly severe at the moment. The pain is very severe at the moment. The pain is the worst imaginable at the moment. SECTION 2 PERSONAL CARE I can look after myself normally without causing pain. I can look after myself normally but it causes pain. It is painful to look after myself and I am slow and careful. I need some help but manage most of my personal care. I need help every day in most aspects of self care. I do not get dressed, I wash with difficulty and I stay in bed. SECTION 3 LIFTING I lift heavy weights without extra pain. I can lift heavy weights but it gives extra pain. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, for example on a table. Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned. I can lift very light weights. I cannot lift or carry anything at all. SECTION 4 - READING I can read as much as I want to with no pain in my neck. I can read as much I want to with slight pain in my neck. I can read as much as I want to with moderate pain in my neck. I can t read as much as I want because of moderate pain in my neck. I can hardly read at all because of severe pain in my neck. I cannot read at all. SECTION 5 HEADACHES I have no headaches at all. I have slight headaches which come infrequently. I have moderate headaches which come infrequently. I have severe headaches which come frequently. I have headaches almost all the time. SECTION 6 CONCENTRATION I can concentrate fully when I want to with no difficulty. I can concentrate fully when I want to with slight difficulty. I have a fair degree of difficulty in concentrating when I want to. I have a lot of difficulty in concentrating when I want to. I have a great deal of difficulty concentrating when I want to. I cannot concentrate at all. SECTION 7 WORK I can do as much work as I want to. I can only do my usual work, but no more. I can do most of my usual work, but no more. I cannot do my usual work. I can hardly do any work at all. I can t do any work at all. SECTION 8 DRIVING I can drive my car without any neck pain. I can drive my car as long as I want with slight pain in my neck. I can drive my car as long as I want with moderate pain in my neck. I can t drive my car as long as I want because of moderate pain in my neck. I can hardly drive at all because of severe pain in my neck. I can t drive my car at all. SECTION 9 - SLEEPING I have no trouble sleeping. My sleep is slightly disturbed(less than 1 hour sleepless). My sleep is mildly disturbed (1-2 hrs. sleepless). My sleep is moderately disturbed (2-3 hrs. sleepless). My sleep is greatly disturbed (3-5 hrs. sleepless). My sleep is completely disturbed (5-7 hrs. sleepless). SECTION 10 RECREATION I am able to engage in all my recreation activities with no neck pain at all. I am able to engage in all my recreation activities, with some pain in my neck. I am able to engage in most, but not all of my usual recreation activities because of pain in my neck. I hardly do any recreation activities because of pain in my neck. I can t do recreation activities at all.

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