Download Kneaded Bodywork Massage Therapy ORTHOPEDIC HISTORY

Kneaded Bodywork Massage Therapy
Page 1 of 3
E-mail Form
Located in Sunkissed Laser & Spa
5203 50th St. Drayton Valley, AB
Print Form
Klee Moyer, RMT, CLT | 780-898-1162
NHPC # 20039
ORTHOPEDIC HISTORY FORM
CLIENT INFORMATION
Today's Date
Last Name
Mobile #
First Name
MI
Date of Birth
How did you hear about us?
Are you able to receive texts?
Provide appropriate address:
Preferred Address to receive insurance claims:
Phone #
Emergency Contact Name
Relationship
Is this a gift card?
What therapeutic services have you booked?
Yes
CHIEF COMPLAINT
What is the main reason for your visit today?
Do you know how this occurred:?
Has the condition (worsened, improved, stayed the same)?
Date of accident or date symptoms began?
List any other health care practitioners you have seen for this problem
List any previous tests or procedures for this problem:
What makes your condition better?
What makes your condition worse?
Explain Injury or Illness:
Describe the symptoms you are having:
Is anything else occurring at the same time?
Nausea
Weight Loss / Gain
Yes
No
Rash
Bloating
Headache
Bleeding
Fatigue
Other
If yes, explain:
How long does the problem last?
Other
Is the problem constant or variable?
Other
Does the problem interfere with your normal functions?
Yes
No
If yes, explain:
Last Name
First Name
Date
Patient Signature
No
Kneaded Bodywork Massage Therapy
Page 2 of 3
E-mail Form
Located in Sunkissed Laser & Spa
5203 50th St. Drayton Valley, AB
Print Form
Klee Moyer, RMT, CLT | 780-898-1162
NHPC # 20039
ORTHOPEDIC HISTORY FORM
PAST MEDICAL, FAMILY & SOCIAL HISTORY
List any personal illness:
List any surgeries and date occurred:
List all serious illnesses in your immediate family. (Example: diabetes, tuberculosis, breast cancer, heart disease, etc.,)
Do you have any drug allergies?
Yes
No
If yes, explain:
Please list all medications you are currently taking!
Do/did you smoke?
Yes
No
Yes
No
Yes
No
Yes
No
If yes, how much and for how long
Do/did you drink?
If yes, how much and for how long
Do you exercise regularly?
If yes, how much:
Are you right or left handed?
If age 55 or older, have you had a Bone Density Test?
Yes
No
HEALTH HISTORY
Are you pregnant?
Yes
Is this your first pregnancy?
No
If yes, how many weeks?
Yes
No
If No, any previous pregnancy complications?
Yes
No
Current concerns/complaints regarding pregnancy?
High or low blood pressure?
Yes
No
Have you taken these medications today?
Diabetes?
Yes
No
Are you currently taking medications/natural remedies for this condition?
Yes
No
Have you taken prescribed medications today?
Type:
Do you have pins, plates or pacemaker?
Yes
Yes
No
Recent Surgeries?
Nut or food allergies?
Last Name
Sensitivities?
First Name
Yes
Date
Patient Signature
No
No
Page 3 of 3
Kneaded Bodywork Massage Therapy
Located in Sunkissed Laser & Spa
5203 50th St. Drayton Valley, AB
E-mail Form
Print Form
Klee Moyer, RMT, CLT | 780-898-1162
NHPC # 20039
ORTHOPEDIC HISTORY FORM
Policy Understanding & Consent to Treat
(Please check each item below)
1. I understand certain medical conditions are contraindicated for massage therapy, meaning
massage therapy can make some conditions WORSE. Therefore, I have been completely honest in
filling out this health questionnaire
2. I understand that my massage therapy sessions, and all of my files, are completely confidential, and
that my information will not be released without both verbal and written consent from me.
3. I understand that Klee Moyer, RMT does not direct bill insurance companies. I will pay for each
treatment, and receive a receipt with my therapists registration number, contact info, treatment and
treatment cost to submit to my insurance company for reimbursement.
4. Cancellation Policy I understand that I must give at least 24 hrs. notice to cancel or reschedule my
appointment. If I am a “no show” more than one time, I understand I may not be able to book
anymore appointments unless I prepay for them. (Note from Klee: I understand “life happens”! If
you are able to give me enough notice to fill your spot, or you know someone else that would take
it, that would be greatly appreciated J.)
5. Illness: As your massage therapist, your health is my Number One Priority. Therefore, if I am sick, I
will reschedule you, and if you are sick, I ask that you please reschedule as well. I sincerely
appreciate your consideration :)
Singature
(If under 18yrs of age, signature of parent or legal guardian