Health History Form

Peaceful Spirit Therapeutic Massage & Wellness Centers Health History Form

Please answer the following questions as completely as possible.Please note this form is used by the massage therapists, chiropractor, and acupuncturists.We understand it is very thorough, but this is to ensure that we provide the best treatments possible.

Today's Date

First Name

Middle Initial

Last Name

Date of Birth

Please enter your stress level

(1= low 10=high)

Hobbies, Favorite Exercise, or Sports

What Type of Work Do You Do?

List any repetitive movements that you do

What would you like to see as an outcome from today

Instructions

Tell us about any pain your have.

Is your condition related to an accident?

If so, what was the date of the accident?

What type of accident?

Automobile
Work
Home
Other

If you marked "Other", please explain

If your pain is not caused by an accident, when did your symptoms begin?

Has your pain been getting progressively worse?

Rate your level of pain (1 = No Pain, 10 = Unbearable pain)

What type(s) of pain are you experiencing (check all that apply)

Sharp
Dull
Throbbing
Numbness
Aching
Shooting
Burning
Tingling
Cramps
Stiffness
Swelling
Other

If you marked "Other", please explain

How often do you have this pain?

Is your pain constant, or does it come and go?

Does your pain interfere with any of the following?(Check all that apply)

Work
Sleep
Daily Routine
Recreation
Other

If you marked "Other", please explain

Activities or movements that are painful to perform (Check all that apply)

Sitting
Standing
Walking
Bending
Lying Down
Other

If you marked "Other", please explain

Select which professional bodywork services you have received (Please select all that apply)

What is the primary reason for receiving the above bodywork?

How frequently are you getting treatments?


If you could change or fix anything about your health, what would it be?

What will you be able to do once those changes happen?


What other changes would you like to see for yourself (not necessarily health-related)?

Are you under the care of a physician?


If yes, for what condition are you under care?

Name of Physician

Physician's Phone Number

Last Visit Date

Are you pregnant?

Select any symptoms you currently have (Please select all that apply)

List any conditions or symptoms you currently have or have had in the past

Select any symptoms or conditions you currently have or have had in the past (Please select all that apply)

List any injuries or surgeries you have had

Do you have any allergies?

If yes, what are you allergic to?

List any vitamins or supplements

List any medications

Please Read and Sign Below

By signing below, I acknowledge that I have read, understand and agree to the statements and policies listed below.

I understand that the treatment can be terminated at any time be either myself or the therapist upon verbal request.

I understand that the L.M.T. does not diagnose illness or disease and does not prescribe medical treatment or pharmaceuticals, nor are spinal manipulations part of massage therapy. It is recommended I work with my PCP for any condition I may have. I have stated all known conditions and medications, and I will keep the L.M.T. updated on changes.

I hereby request and consent to the performance of therapeutic massage and acupuncture and other complementary and alternative medicine treatments as requested by the client/patient.

I understand that all fees are due at time of treatment, unless prior arrangements have been approved. I understand that I am responsible for all collection costs, interest and appropriate legal fees for the collection of any unpaid debts to Peaceful Spirit or their affiliates.

Peaceful Spirit Therapeutic Massage Center LLC is pleased to file an insurance claim (in pre-approved cases) for you in the case of personal injury, worker's compensation or health insurance. Please understand that the benefit contract is an agreement between you and the insurance company (or your employer or at fault party's insurance company), and that verification of benefits is not a guarantee of payment. You are fully responsible for any and all services rendered to you. All reasonable efforts will be made to collect sums due from the insurance companies that are contractually obligated. If you receive a payment from the insurance company, this payment must be brought into the office and shall be applied to the balance due. I assign directly to Peaceful Spirit Therapeutic Massage Center LLC, or it's divisions all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance, even if prior authorization was granted.

I acknowledge receipt of Notice of Privacy Practices sent under separate cover. I hereby authorize Peaceful Spirit Therapeutic Massage Center LLC, or it's divisions to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all submissions. A photo copy of the assignment lien and my signature shall be considered effective and valid as original.

The Peaceful Spirit Massage Therapy and Chiropractic cancellation policy is as follows: 24 hours notice of cancellation must be given or I will be billed $20 for a missed one-hour or shorter appointment or $50 for a two hour or longer appointment. All other services will be billed at current rate.

I agree to the above terms and conditions

Signature

Instructions

Complete this section if your problem is due to an accident.

Type of Accident

Automobile
Work
Home
Other

If you marked "Other", please explain

To whom have you made a report of your accident?

What type of insurance will you be billing?

Auto Insurance
Employer
Worker's Comp
Other

Attorney name (if applicable)

What treatment(s) have you already received for your condition?

Medications
Surgery
Physical Therapy
Acupuncture
Massage
Chiropractic Care
None
Other

If you marked "Other", please explain

Name and address of other doctor(s) who have treated you for your condition

If another doctor has treated you for this condition, please enter the date of the first treatment

If another doctor has treated you for this condition, please enter the number of treatments you have had in the last 12 months

When was your last physical exam?


Have you received any of the following because of your condition?

Physical Exam
Spinal X-Ray
Blood Test
Spinal Exam
Chest X-Ray
Urine Test
Dental X-Ray
MRI
CT Scan
Bone Scan

If you checked any of the boxes above, please indicate the dates you received each treatment

Informed Consent (Chiropractic)

If you are currently scheduled with our chiropractor or plan to become a chiropractic patient in the future, please complete this form.

Dear Patient: Please feel free to discuss any questions or concerns with the Doctor before signing this consent.

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays, on me (or the patient named below, for whom I am legally responsible) by the doctor of chiropractic named above.

I have had the opportunity to discuss with the doctor and/or with other clinic personnel the purpose and benefits of the chiropractic adjustment and other treatments outlined below. Alternatives to treatment have been reviewed.

Though chiropractic adjustments and treatments are usually beneficial and rarely cause any problem, I understand and informed that there are some risks to treatment. Risks include, but are not limited to, sprains, fractures, dislocations, disc injury and stroke.

I understand that I will be receiving the following treatment:

  • Chiropractic adjustments (manually, or by adjusting instruments)
  • lectric muscle stimulation
  • Ultrasound
  • Myotherapy-soft tissue therapies
  • X-Ray
  • Rehabilitative Exercise
  • Other modalities

therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the chiropractic treatment that I have requested and authorized. I have had the opportunity to read this form and ask questions. Any question that I have had regarding my care has been answered to my satisfaction. I consent to the proposed treatment.

I agree to the above terms and conditions

Signature


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