Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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