BOTHELL INTEGRATED HEALTH, LLC Therapeutic Massage

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BOTHELL INTEGRATED HEALTH, LLC Therapeutic Massage Patient Name Date Address City State Zip Phone (home) (cell) Emergency Contact Name Phone Employer Date of Birth Work Phone Social Security # Is condition due to an injury? No Yes If yes: MVA L&I Other Date of Injury Do you have a claim currently open? Yes No Name of Referring Physician Phone MEDICAL INSURANCE INFORMATION Insurance Company Primary Card Holder Number Group Number (If other than self) Name & Relationship Date of Birth Secondary Insurance Card Number Group Number L & I INSURANCE INFORMATION (Required if you have been injured on the job.) Insurance Company Claims Adjuster Claim Number 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 Location of Accident (street, area, etc.) Insurance Claim Number Name of Your InsuranceCompany Bothell Integrated Health, LLC (revised 1/22/07) Page 1 of 8

AUTO INSURANCE INFORMATION (Continued) Address City State Zip Claims adjuster Phone At-Fault Party's Name Insurance Company Phone Claims Adjuster Claim Number 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 Bothell Integrated Health, LLC 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 Bothell Integrated Health, LLC 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 Bothell Integrated Health, LLC 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. All accounts with a past due amount over 60 days will accrue interest at the rate of 1% per month. Date Patient Signature (If patient is a minor, signature of parent or guardian is required) Bothell Integrated Health, LLC (revised 1/22/07) Page 2 of 8

WELCOME TO BOTHELL INTEGRATED HEALTH You have made an appointment at Bothell Integrated Health 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 last 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 $35 fee. A patient who arrives more than 15 minutes late for an appointment may be asked to reschedule that appointment. We appreciate your consideration and ask that you fill out the intake forms completely so that your Therapist is able to provide you with the most effective treatment possible. I have read the above statement and I understand that I am responsible for paying to Bothell Integrated Health a $35 fee for any appointment missed without at least 24 hours prior notice. Signature: Date: Bothell Integrated Health, LLC (revised 1/22/07) Page 3 of 8

MASSAGE PATIENT QUESTIONNAIRE Name Date: Occupation Have you received massage before? Comments: 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 medications or homeopathics? Yes No If yes, please explain: Have you ever experienced any of the following conditions? Please use C for Current or P for Past. Aids Allergies Anemia Arthritis Back Pain Broken Bones Bursitis Cancer Chronic Fatigue Syndrome Circulation Problems Colitis Constipation Diarrhea Diabetes Digestive Problems Disk Problems Diverticulitis Epilepsy Seizures Fibromyalgia Headaches Heart Ailments Hemophilia Herpes Virus High Blood Pressure Insomnia Low Blood Pressure Migraine Headaches Muscle Spasms Numbness Phlebitis Psoriasis Rashes Ringworm Sciatica Skin Allergies Stress Stroke Swollen Feet/Legs Tendonitis Thoracic Outlet Syndrome Tingling TMJ Dysfunction Varicose Veins Whiplash For Women Only: Excessive Bleeding Lack of Periods Menstrual Cramps PMS Comments: Bothell Integrated Health, LLC (revised 1/22/07) Page 4 of 8

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: Heavy Medium Light How often do you exercise: 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 a massage? Bothell Integrated Health, LLC (revised 1/22/07) Page 5 of 8

PERSONAL STATUS REPORT Name: Date: Identify CURRENT symptomatic areas in your body by drawing the symbols on the figures below. Key: X Circle areas of PAIN X over areas of JOINT AND MUSCLE STIFFNESS Draw a squiggly line along the areas of NUMBNESS OR TINGLING Mark SCARS, BRUISES or OPEN WOUNDS Additional Comments: Bothell Integrated Health, LLC (revised 1/22/07) Page 6 of 8

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 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 vary much. SECTION 2- PERSONAL CARE I would not have to change my way of washing or dressing in order to avoid pain. I do not normally change my way of washing and dressing even though IT causes some pain. Washing and dressing increase the pain but I manage not to change my way of doing IT. Washing and dressing increase the pain and I find i1 necessary to change my way of doing it. Because of the pain I am unable to do some washing and dressing. Because of the pain I am unable to do any washing and dressing without help. SECTION 3- LIFTING I can lift heavy weights without extra pain. I can lift heavy weights but it causes extra pain. Pain prevents me from lifting heavy weights off the floor. Pain prevents me from lifting heavy weights off the floor, but I manage if they are conveniently positioned (e.g. on a table). Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positione d. I can only lift very light weights at the most. SECTION 4- WALKING I have no pain on walking. I have some pain on walking but it does not increase with distance. I cannot walk more than one mile without increasing pain. I cannot walk more than 1/2 mile without increasing pain. I cannot walk more than 1/4 mile without increasing pain. I cannot walk at all without increasing pain. SECTION 5- SITTING I can SIT in any chair as long as I like. I can only SIT in my favorite chair as long as I like. Pain prevents me from sitting more than one hour. Pain prevents me from sitting more than 1/2 hour. Pain prevents me from sitting more than 10 minutes. I avoid sitting because it increases my pain straight away. 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 1/2 hour without increasing pain.' I cannot stand for longer than 10 minutes wi1hout increasing pain. I avoid standing because it increases the pain straight away. SECTION 7- SLEEPING I get no pain in bed. I get pain in bed but it does not prevent me from sleeping well. Because of pain my normal night's sleep is reduced by less than ¼. Because of pain my normal night's sleep is reduced by less than ½. Because of pain my normal night's sleep is reduced by less than ¾. Pain prevents me from sleeping at all. SECTION 8- SOCIAL LIFE My social life is normal and gives me no pain. My social life is normal but increases the degree of pain. Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g. dancing, etc. Pain has restricted my social life and I do not go out very often. Pain has restricted my social to my home. I have hardly any social life because of the pain. SECTION 9- TRAVELLING I get no pain whilst traveling. I get some pain whilst traveling but none of my usual forms of travel make it any worse. I get extra pain whilst traveling but it does not compel me to seek alternate forms of travel. I get extra pain whilst traveling which compels me to seek alternative forms of travel. Pain restricts all forms of travel. Pain prevents all forms of travel except that done lying down. SECTION 10- CHANGING DEGREE OF PAIN My pain is rapidly getting better. My pain fluctuates but overall is definitely getting better. My pain seems to be getting better but improvement is slow at present. My pain is neither getting better or worse. My pain is gradually worsening. My pain is rapidly worsening. Bothell Integrated Health, LLC (revised 1/22/07) Page 7 of 8

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 neck 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 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 (washing, dressing etc.) I can look after myself normally without causing pain. I can look after myself normally but it causes extra 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 can lift heavy weights without extra pain. I can lift heavy weights but it gives extra pain. Pain prevents me from lifting heavy weights off 1he 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 positione d.. 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 as 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 moderate headaches which come frequently I have severe headaches which come frequently. I have headaches almost all of 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 sligh1 difficulty. I have a fair degree of difficulty in concentrating when I want to. I have a great deal of difficulty in 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 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 one 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 am able to engage in a few 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. Bothell Integrated Health, LLC (revised 1/22/07) Page 8 of 8

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