Confidential Health Intake Form
Name _______________________________________________________
Street Address ________________________________________________ City__________________
State_____ Zip__________________________
Date of Birth _________________________________________________
Work Phone _______________________ Home phone_________________ Cell Phone/pager______________
Emergency Contact _____________________________________________
Employer ____________________________________________________
Social Security Number _________________________________________
Occupation __________________________________________________
Referring Physician:_____________________________________________
Primary Care Physician:__________________________________________
Insurance Information:
Was Injury a result of an accident?_________ If yes: Job related________
Auto ________ Other_________
Date of Injury or onset: ________________________
Referring Physician_____________________________
Insurance Company
Name:__________________________________________________________
Billing Address:__________________________________________________
Phone Number:__________________________________________________
Contact person/ case manager _______________________________________
Name of Insured :________________________________________________
Address:_______________________________________________________
Phone:_________________________________________________________
Group/Claim Number: ____________________________________________
Attorney (if applicable)
Name :_______________________________________________________
Address:______________________________________________________
Phone number: _________________________________________________
I hereby authorize the release of medical information necessary to process
my insurance claim. This may include intake forms, chart notes, reports,
correspondences, billing statements and any other information to my attorneys,
health care providers and insurance case managers.
I am responsible for all charges for all services provided. In the event
that the insurance company denies benefits or makes a partial payment,
I am responsible for any balance due. This may not apply to insurance companies
that I am under contract with.
I understand the benefits and risks of massage and give my consent for
massage. I will consult my practitioner with any questions or concerns
immediately.
I have stated all medical conditions that I am aware of and will keep
my practitioner informed of any changes.
I agree to provide 24 hour cancellation notice. If I fail to
do so, I agree to pay the full appointment fee. (Please note that
insurance companies do not pay this, you do.)
Signature ____________________________________________________
Date _______________________________________________________
Medical History and Information
Check any or all that apply to your present health:
___ headaches ___chronic pain ___varicose veins
___ vision problems ___muscle or joint pain ___blood clots
___ sinus problems ___numbness/tingling ___high/low blood pressure
___ jaw pain/teeth grinding ___sprains/strains ___diabetes
___ fatigue ___scoliosis ___cancer/tumors
___ depression ___arthritis ___infectious disease
___ sleep difficulties ___tendonitis ___skin problems
Women only: Pregnant___ Painful menstruation___ endometriosis___
Men only: Prostrate problems___
List all medications/herbs/vitamins and dosage: _____________________________________________________________
____________________________________________________________
List physical activities you participate in regularly____________________________________________________
Describe the events of the injury or accident: ____________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
List previous major injuries/surgeries: ___________________________________________________________
_________________________________________________________________________________________
What other treatments are you receiving and by whom (acupuncture, physical
therapy, chiropractic, naturopathic): ______________________________________________________________________________
_________________________________________________________________________________________
What seems to help the most? ________________________________________________________________
What seems to aggravate the condition the most?_________________________________________________
What is your main activity at work? On phone ________ Sitting________
Computer work____________
Driving car_____________ Walking_____________
Other _______________________________________
What do you do to relieve stress______________________________________
______________________________________________________________
Practitioner Comments_____________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
