Home | Blog | About Me | Websites for Massage Therapists | Business Coaching | Search |
|
|
Name _______________________________________________________ Work Phone _______________________ Home phone_________________ Cell Phone/pager______________ Emergency Contact _____________________________________________ Employer ____________________________________________________ Referring Physician:_____________________________________________ Insurance Information: Was Injury a result of an accident?_________ If yes: Job related________ Date of Injury or onset: ________________________ Insurance Company
Name:__________________________________________________________ Name of Insured :________________________________________________ Group/Claim Number: ____________________________________________ Attorney (if applicable) 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 ____________________________________________________ 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_____________ What do you do to relieve stress______________________________________ Practitioner Comments_____________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________
|
|
