Practitioner/Clinic Name: Health Information Forms.… · Associated Bodywork & Massage...
Transcript of Practitioner/Clinic Name: Health Information Forms.… · Associated Bodywork & Massage...
Associated Bodywork & Massage Professionals
MEMBER
Practitioner/Clinic Name: ____________________ Health Information
Contact Information: ________________________ (page 1 of 2) Client Contact Information Client Name: ___________________________________ Date: ____________ Date of Birth: ____________ Gender: ____________ Address: _________________________________________________________________________________ Phone: _______________________________________ Email: ___________________________________ Referred by: ___________________________________ Emergency contact: _____________________________ Phone: ___________________________________ Physician/Health-care Provider name: __________________________ Phone: ____________________ Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)? Yes ☐ No ☐ Do you have a physician referral/prescription? Yes ☐ No ☐ Are you seeking insurance reimbursement? Yes ☐ No ☐ If yes, please complete the Billing Information form. Type of insurance coverage for this claim: Car Collision Worker’s Compensation Private Health Massage Information Have you ever received professional massage/bodywork before? Yes ☐ No ☐ How recently? ___________________________________ What types of massage/bodywork do you prefer? ___________________________________ What kind of pressure do you prefer? Light Medium Firm What are your goals/expected outcomes for receiving massage/bodywork? _________________________________________________________________________________________ _________________________________________________________________________________________ How do you feel today? ______________________________________________________________________ List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.): ____________________________________________________________________________________________________________________________________________________________________________________________ Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)? Yes No Explain: ____________________________________________________________________________________________________________________________________________________________________________________________ List the medications you currently take: ____________________________________________________________________________________________________________________________________________________________________________________________ Are you wearing contacts? Yes ☐ No ☐ Are you wearing dentures? Yes ☐ No ☐ Are you wearing a hairpiece? Yes ☐ No ☐ Are you pregnant? Yes ☐ No ☐
Associated Bodywork & Massage Professionals
MEMBER
Practitioner/Clinic Name: ____________________ Health Information
Contact Information: ________________________ (page 2 of 2)
Health History Have you had any injuries or surgeries in the past that may influence today’s treatment? ______________________________________________________________________________________________ Circle any of the following health conditions that you currently have (If you are unsure, please ask): blood clots, infections, congestive heart failure, contagious diseases, pitted edema Please answer honestly, as massage may not be indicated for the above conditions.
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Current Past Muscle or joint pain _____________________________________ Current Past Muscle or joint stiffness _____________________________________ Current Past Numbness or tingling _____________________________________ Current Past Swelling _____________________________________ Current Past Bruise easily _____________________________________ Current Past Sensitive to touch/pressure _____________________________________ Current Past High/Low blood pressure _____________________________________ Current Past Stroke, heart attack _____________________________________ Current Past Varicose veins _____________________________________ Current Past Shortness of breath, asthma _____________________________________ Current Past Cancer _____________________________________ Current Past Neurological (e.g. MS, Parkinson’s, chronic pain) _____________________________________ Current Past Epilepsy, seizures _____________________________________ Current Past Headaches, Migraines _____________________________________ Current Past Dizziness, ringing in the ears _____________________________________ Current Past Digestive conditions (e.g. Crohn’s, IBS) _____________________________________ Current Past Gas, bloating, constipation _____________________________________ Current Past Kidney disease, infection _____________________________________ Current Past Arthritis (rheumatoid, osteoarthritis) _____________________________________ Current Past Osteoporosis, degenerative spine/disk _____________________________________ Current Past Scoliosis _____________________________________ Current Past Broken bones _____________________________________ Current Past Allergies _____________________________________ Current Past Diabetes _____________________________________ Current Past Endocrine/thyroid conditions _____________________________________ Current Past Depression, anxiety _____________________________________ Current Past Memory Loss, confusion, easily overwhelmed _____________________________________
Comments: ______________________________________________________________________________________________ ______________________________________________________________________________________________
Consent for Treatment If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care. Client Signature: _____________________________________________________________ Date: ____________ Parent or Guardian Signature (in case of a minor): ___________________________________ Date: ____________
Associated Bodywork & Massage Professionals
MEMBER
Practitioner/Clinic Name: Screening Questionnaire
Contact Information (page 1 of 2)
Client Information Client Name: Date:
Preferred phone number: Best time to call:
Email address: Preferred form of communication:
Massage Information How did you hear about me? (referral, Facebook, etc.) Is this a gift certificate? Yes ☐ No ☐ Massage history: Have you had a massage/bodywork before? Yes ☐ No ☐
Frequency:
Types of massage/bodywork received:
Preferred types of massage:
Reasons for seeking massage? (relaxation, injury, etc.)
Description of injury/health condition:
Possible complications/medications:
Expected outcomes (functional improvement, symptom relief, wellness):
Typical activities of daily living (affected by condition?):
Occupation (affected by condition?): Are you seeking insurance reimbursement? Yes ☐ No ☐ Car collision/personal injury?
On-the-job injury?
Private health insurance?
Do you have a physician referral with diagnosis codes?
Let clients know if you provide billing services, and if so, for what types of claims, or if you will simply provide receipts and/or copies of records for them to submit for reimbursement. Let clients know a physician referral demonstrating medical necessity is required for insurance reimbursement/health savings account reimbursement regardless of who submits bills. Best times for massage:
Associated Bodywork & Massage Professionals
MEMBER
Practitioner/Clinic Name: Screening Questionnaire
Contact Information (page 2 of 2) Communication Checklist ❏ Fees/forms of payment ❏ Cancellation/No-show policy ❏ Late arrival policy ❏ Confidentiality ❏ Parking/directions ❏ Work setting ❏ Clothing/shiatsu ❏ Modesty/Nonsexual/draping ❏ Food/drugs/alcohol ❏ Oils/lotions/allergies
Do you have special needs I should prepare for:
Do you have any questions or concerns:
If out-call, ask for directions, parking, or special instructions:
Packet Checklist
❏ Health Information ❏ Health Status Report ❏ Billing Information ❏ Directions/map
Date sent Additional Notes
Associated Bodywork & Massage Professionals
MEMBER
Practitioner/Clinic Name: ____________________ Body Map
Contact Information: ________________________
Name: ___________________________________________ Date: ____________
Note the finding next to the muscle checked: T = Tension, hypertonicity P = Pain S = Spasm I = Inflammation N = Numbness/tingling
Deltoid
Tricep
Soleus
Biceps Femoris
Iliotibial Tract
Semitendinosis
Lumbodorsal Fascia
External Abdominal Obliques
Semispinalis Capitis
Anconeus
Extensor Carpi Ulnaris
Infraspinatus
Gluteus Maximus
Latissimus Dorsi
Tensor Fascia Latae
Semimembranosus
Adductor Magnus
Plantaris
Trapezius
Gastrocnemius
Calcaneal Tendon (Achilles)
Deltoid
Biceps Brachii
Brachialis
Brachioradialis
Flexor Carpi Radialis
Flexor Carpi Ulnaris
Frontalis Temporalis
Procerus
Buccinator
Trapezius
SternocleidomastoidDepressor Anguli OrisOrbicularis Oculi
Orbicularis Oris
Pectoralis Major
External Abdominal Obliques
Pronator Teres
Masseter
Extensor DigitorumCommunis Longus
Rectus Femoris
Gastrocnemius
Adductor LongusPectineus
Adductor Magnus
Vastus Medialis
SoleusPatellar Ligament
SartoriusTensor Fascia Latae
Vastus Lateralis
Gracilis
Peroneus Longus
Cruciate Ligament
Tibialis Anterior
Iliopsoas
Serratus Anterior
Rectus Abdominis
Arm ❏ Biceps/Tricep Supinator ____ ❏ Brachialis ____ ❏ Coracobrachialis ____ ❏ Deltoids: Ant/Lat/Post ____ ❏ Pronator Teres ____
Hip/Leg ❏ Add Long/Brev Mag ____ ❏ Biceps Femoris ____ ❏ Gemellus Sup/Inf ____ ❏ Gluteus Max/Med/Min ____ ❏ Obturator Int/Ext ____ ❏ Pectineus ____ ❏ Piriformis ____ ❏ Iliopsoas Major/Illacus ____ ❏ Quadratus Femoris ____ ❏ Rectus Femoris ____ ❏ Sacrospinalis ____ ❏ Sartorius/Gracilis ____ ❏ Semi-Tend/Membranosus ____ ❏ Tensor Fascia Latae ____ ❏ Trochanteric ____ ❏ Vastus Int/Med/Lat ____
Chest ❏ Diaphragm ____ ❏ Ext/Int Oblique ____ ❏ Intercostals ____ ❏ Pectoralis Major/Minor ____ ❏ Rectus Abdominis ____ ❏ Ribs ____ ❏ Serratus Anterior ____ ❏ Subclavius ____ ❏ Transverse Abdominis ____
Foot ❏ Abd/Add Hallucis Brev ____ ❏ Abductor Digiti Brevis ____ ❏ Dors/Plan Interossei ____ ❏ Flexor Digiti Minimi Brevis ____ ❏ Flexor Digitorum Brevis ____ ❏ Flexor Hallucis Brevis ____ ❏ Lumbricals ____ ❏ Quadratus Plantae ____ ❏ Calcaneal Tendon(Achilles) ____
Neck ❏ Scalenes Anter/Med/Post ____ ❏ Splenus Capitus ____ ❏ Splenus Cervicus ____ ❏ Sternocleidomastoid ____ ❏ Supra Infra Hyoids ____
Head ❏ Auricularis Post/Sup ____ ❏ Buccinator ____ ❏ Masseter ____ ❏ Orbicularis Oris/Oculi ____ ❏ Pterygoid Med/Lat ____ ❏ Transverse Nuchae ____ ❏ Temporalis ____
Lower Leg ❏ Flex/Ext Digitorum Long/BR ____ ❏ Flex/Ext Hallucis Long ____ ❏ Gastrocnemius ____ ❏ Peroneus Tert/Brev/Lon ____ ❏ Plantaris/Popliteus ____ ❏ Soleus ____ ❏ Tibialis Post/Ant ____
Back ❏ Erector Spinae ____ ❏ Iliocostalis ____ ❏ Infraspinatus ____ ❏ Interspinalis ____ ❏ Intertransversarii ____ ❏ Latissimus Dorsi ____ ❏ Levator Scapula ____ ❏ Longissimum ____ ❏ Multifidus Rotatores ____ ❏ Quadratus Lumborum ____ ❏ Rhomboids: Major/Minor ____ ❏ Serratus Post/Sup/Inf ____ ❏ Spinalis/Semispinalis ____ ❏ Subscapularis ____ ❏ Supraspinatus ____ ❏ Teres Major/Minor ____ ❏ Trapezius ____
Associated Bodywork & Massage Professionals
MEMBER
Practitioner/Clinic Name: ____________________ Health Status Update
Contact Information: ________________________ Client Information Client Name: ______________________________ Date: ____________________ Date of Birth: _______________
Depict how you are feeling today by drawing a circle on the figures representing the size and shape of the following symptoms. Place the letter representing the symptoms in or near the circle:
Rate how you are feeling today by drawing a circle around the number that best represents how you are doing today: No pain 0 1 2 3 4 5 6 7 8 9 10 Worst pain imaginable Able to do everything 0 1 2 3 4 5 6 7 8 9 10 Not able to do anything Comments Is there anything else I should know about how you are feeling today or about your progress or care to date?
Signature: _________________________________________ Date: _________________
P = Pain, ache, or tenderness S = Stiffness in the joint or muscle
L L R R
Associated Bodywork & Massage Professionals
MEMBER
Practitioner/Clinic Name: ____________________ Physician/Health-Care
Contact Information: ________________________ Provider’s Permission Patient Information Patient Name: _________________________________ Date of Birth: ______________ Permission Granted to Provider Name: _______________________________ Specialty/Type of Treatment: ________________________ Reason for Permission There is no reason to believe that massage or bodywork treatments will harm this patient’s progress. However, please note the following considerations: Description of condition:
Possible interactions with medications:
Special instructions:
Permission Granted by Physician/Health-Care Provider Name: ___________________________________________________________________ Phone: ________________________ Fax: ________________________ Email: __________________________ Signature: ___________________________________ Date: __________________ Please note: Should you notice anything unusual or significant during treatment, please notify this office immediately. Otherwise, any update at the conclusion of care would be appreciated.
Associated Bodywork & Massage Professionals
MEMBER
Practitioner/Clinic Name: Physician/Health-Care
Contact Information Provider’s Referral Patient Information Patient Name: Date of Birth: Insurance ID#: Date of Injury/Illness: Referred to Provider Name: Specialty/Type of Treatment: Reason for Referral Diagnosis codes—ICD-9/10: Number of visits (frequency/duration): Is the referral for medically necessary treatment? Yes ☐ No ☐ Description of condition:
Possible precautions due to condition:
Possible interactions with medications:
_
Referred by Physician/Health-Care Provider Name: Phone: Fax: Email: Signature: Date: Please note: Should you notice anything unusual or significant during treatment, please notify this office immediately. Otherwise, a summary report at the end of treatment is appreciated.
Associated Bodywork & Massage Professionals
MEMBER
(page 1 of 2)
Practitioner/Clinic Name: ____________________ Billing Information
Contact Information: ________________________
Patient Information Name: ___________________________________________________ Date: _______________
Address: __________________________________________________________________________________
Phone: ___________________________________ Email: ____________________________________
Gender: ____________ Marital status: _____________ Date of birth: _________________
Social security number: _________________________ Date of injury: ________________
Referring healthcare provider: _________________________________________________________________
Phone: ___________________________________ Email: ____________________________________
Address: __________________________________________________________________________________
Primary Insurance Information (e.g., Car Insurance if an auto accident, Worker’s Comp if an on-the-job injury, Health Insurance if an illness, etc.) Insurance company: ______________________________________ Phone: _____________________
Address: _________________________________________________________________________________
Insurance ID# (include alpha prefix): _____________________ Group Plan #: _______________________
Name of insured (if other than you): _____________________________________________________________
Relationship to insured: __________________________ Insured’s SS#: ______________________________
Insured’s date of birth: ___________________________ Insured’s gender: ____________________________
Adjuster’s name: ________________________________ Phone: ________________ Fax: _______________
Secondary Insurance Information (if applicable) Insurance company: ______________________________________ Phone: _____________________
Address: _________________________________________________________________________________
Insurance ID# (include alpha prefix): _____________________ Group Plan #: _______________________
Name of insured (if other than you): _____________________________________________________________
Relationship to insured: __________________________ Insured’s SS#: ______________________________
Insured’s date of birth: ___________________________ Insured’s gender: ____________________________
Adjuster’s name: ________________________________ Phone: ________________ Fax: _______________
Associated Bodywork & Massage Professionals
MEMBER
Practitioner/Clinic Name: ____________________ Billing Information
Contact Information: ________________________ (page 2 of 2)
Motor Vehicle Collision (Additional information is necessary if billing your car insurance) Auto collision in what state? ____________________________
Job-related collision? Yes ☐ No ☐
Was the collision your fault? Yes ☐ No ☐
PIP policy amount: _______________ Dates of coverage: _____________ PIP available: ________________
MedPay policy amount: ___________ Dates of coverage: _____________ MedPay available: ____________
Liability policy amount: ____________ Dates of coverage: _____________ Liability available: _____________
Attorney Name (if applicable): ______________________________________ Date retained: ________________
Phone: __________________ Fax: _______________________ Email: _______________________________
Address: ____________________________________________________________________________________
Worker’s Compensation (Additional information is necessary if billing State or Federal Labor Insurance) Have you received any massage/bodywork for this injury/claim? Yes ☐ No ☐
# of sessions: ____________ Date claim opened: ____________ Dates of coverage: ____________
Private Health (Additional information is necessary if billing your health insurance) Does the insurance plan cover massage therapy? Yes ☐ No ☐
Does it cover massage therapy provided by a massage therapist (LMT, LMP, RMT, CMT, etc)? Yes ☐ No ☐
Does it cover massage therapy for this condition (____________________)? Yes ☐ No ☐
Does the treatment have to be referred? Yes ☐ No ☐ Prescribed? Yes ☐ No ☐
Does the treatment have to be pre-authorized? Yes ☐ No ☐
What is the annual massage therapy benefit (# of visits or $ amount)? ______________
How much is remaining for this year? _______________________
Do the benefit limits include PT, DC as well? Yes ☐ No ☐ How much is remaining for this year? ________________
What is the deductible? _____________ How much as been satisfied to date? _____________
Is there a co-pay? Yes ☐ No ☐ How much? _______________________
Does the massage/bodywork practitioner have to be a preferred/credentialed provider in the network? Yes ☐ No ☐
Is _________________________ a preferred/credentialed provider? Yes ☐ No ☐
Are there out-of-network benefits available? Yes ☐ No ☐
If yes, what % is covered/what is the co-insurance payment? ______________
What is the deductible for out-of-network care? _______________________
How much has been satisfied to date? __________________