PROFESSIONAL MASSAGE THERAPY CLIENT HISTORY & INTAKE INFORMATION. Date of Birth: / / Address: City, State, Zip:

Transcription

1 PROFESSIONAL MASSAGE THERAPY CLIENT HISTORY & INTAKE INFORMATION Today s Date: / / Name: Date of Birth: / / Address: City, State, Zip: Phone (home): (other): Occupation/Work Description: In Case of Emergency, please contact (name & phone): How Did You Hear About Me? GENERAL MEDICAL INFORMATION (Please explain any Yes answers to the following) Please check the box for a Yes answer on the following: Have you ever had a therapeutic massage? Do you suffer from migraine headaches? Are you wearing contact lenses? Are you epileptic? Are you allergic to nut oils? Do you have phlebitis or varicose veins? Do you have (or suspect you have) fibromyalgia? YES NO Are you pregnant? If so, due date: Is this high risk? Are you diabetic (insulin dependent)? If so, please state injection site: Do you have high blood pressure? If so, is it under control? Do you have any heart, liver, or kidney conditions? Do you have cancer? If so, which type? Do you have any irritable skin disorders? Do you have any prostheses or implants in areas that may be irritated by massage? Are you currently taking any medications? If so, please list: Have you had any surgeries in the last year? If so, please list: Please list areas where you have had major scars/surgeries: Please list the areas of your body which experience regular pain: Are you currently under treatment by a Chiropractor, Homeopath, or other alternative health provider? Is there a reason why you feel you shouldn t lay on your back or stomach? Is there anything else you want me to know? Please turn over for more...

2 I am experiencing the following signs and symptoms (note: these may be used in lieu of a practitioner s diagnosis codes, should they not be available): Headache Pain in the neck Mid-back/thoracic spine pain Low back/lumbar spine pain Backache, unspecified Abdominal pain Pain in a joint: Shoulder and/or collarbone region Upper arm and/or elbow Forearm and/or wrist Hand Pelvis, hip and/or thigh Lower leg and/or kneecap Ankle and/or foot Ribs Multiple sites Stiffness in a joint: Shoulder and/or collarbone region Upper arm and/or elbow Forearm and/or wrist Hand Pelvis, hip and/or thigh Lower leg and/or kneecap Ankle and/or foot Ribs Multiple sites Please take a moment to carefully read the following agreement and sign where indicated. Should you have any questions about the following agreement, please ask me before signing. I,, understand that the massage therapy I receive from Gigi J. Decker is provided solely for the purposes of relaxation, stress reduction, and relief of pain due to soft-tissue restrictions, unless otherwise specified by a referring physician. If I experience any pain or discomfort during my session, it is my responsibility to inform Gigi J. Decker, so that the pressure of the strokes may be adjusted to my comfort level. Because therapeutic massage may be contraindicated in certain medical situations, I affirm that I have honestly answered the questions on the other side of this form, and have informed Gigi J. Decker of all known medical conditions. I agree to update Gigi J. Decker as to any changes in my medical conditions for future sessions, and understand there shall be no liability on Gigi J. Decker s part should I forget to do so. It is also understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of my session, and I will be liable for payment of the full scheduled appointment. I also agree that I will give 24 hours notice in case of appointment cancellation or change. Any less than 24 hour notice, and I agree to personally pay Gigi J. Decker a $25 courtesy fee (subject to increase), due in full before my next visit. I attest that I have received and read a copy of the Client Bill of Rights. I, the above named, agree to all statements within. Signature of client Date Signature of Gigi J. Decker Date

3 In July 2001, a bill was passed which requires all practitioners of complementary and alternative health care to provide their clients with a Bill of Rights before treatment. A copy is to be provided to each client, and a copy must be posted at the office. My Client Bill of Rights is as follows: Complementary & Alternative Health Care Client Bill of Rights Owner/Operator: Gigi J. Decker Credentials: BA in Holistic Health Studies from Augsburg College (Mpls, MN), National Certification in Therapeutic Massage and Bodywork, Certification in Basic Esalen Massage from the Minneapolis School of Massage and Bodywork, Certification in Basic Swedish Massage from the Center For a Balanced Life School of Massage, Certification in Connective Tissue Massage (Latz Technique), Training in Visceral Manipulation (Barral Technique), Active Professional Member of the American Massage Therapy Association, Certified KinesioTaping Practitioner THE STATE OF MINNESOTA HAS NOT ADOPTED UNIFORM EDUCATIONAL AND TRAINING STANDARDS FOR ALL COMPLEMENTARY AND ALTERNATIVE HEALTH CARE PRACTITIONERS. THIS STATEMENT OF CREDENTIALS IS FOR INFORMATION PUR- POSES ONLY. Under Minnesota law, an unlicensed complementary and alternative health care practitioner may not provide a medical diagnosis or recommend discontinuance of medically prescribed treatments. If a client desires a diagnosis from a licensed physician, chiropractor, or acupuncture practitioner, or services from a physician, chiropractor, nurse, osteopath, physical therapist, dietitian, nutritionist, acupuncture practitioner, athletic trainer, or any other type of health care provider, the client may seek such services at any time." 1. You have the right to file a complaint against my services. Complaints should be addressed to (in the following order): a) Gigi J. Decker Current Massage Office:, Suite 200-F3, b) Office of Unlicensed Complementary and Alternative Health Care Practice located in Minnesota Department of Health: P.O. Box 64882, St. Paul, MN Phone: Fax: Website: 2. You have the right to know my fees up front, before receiving service, and to receive reasonable notice of changes in services or charges. These fees are posted in my brochures, and changes will be announced in newsletters and posted on my website. 3. You have the right to be informed of the theoretical approach behind my services, including the course of treatment / expected duration of treatment, before actually receiving the service. 4. You are entitled to courteous treatment free of physical, verbal, emotional or sexual abuse, given in a safe environment with suitable privacy. 5. All of your records and transactions are confidential, unless the release of your records is authorized in writing by you. 6. You have the right to access your records. 7. You have the right to know that other, similar services are available in the area. You may call THE-AMTA to receive referrals to other qualified practitioners. 8. You have the right to choose freely among available practitioners. Should you choose to change practitioners, you have the right to a coordinated transfer. 9. You have the right to refuse treatment, unless otherwise provided by the law. 10. You may assert your rights without retaliation. CODE OF ETHICS 1. I will demonstrate my commitment to provide the highest quality massage therapy/bodywork to those who seek my professional service. 2. I acknowledge the inherent work and individuality of each person by not discriminating or behaving in any prejudicial manner with clients and/or colleagues, including not treating or discontinuing treatment to a client with whom my objectivity would be impaired. 3. I will provide a referral to other qualified practitioners for clients where there is a likelihood that a client needs to be seen by a different practitioner. 4. I will demonstrate professional excellence through regular self-assessment of strengths, limitations, and effectiveness by continued education and training. 5. I acknowledge the confidential nature of the professional relationship I have with clients and respect each client s right to privacy. 6. I will conduct all business and professional activities within their scope of practice, the law of the land, and project a professional image. I will avoid advertising or professional titles that are misleading, deceptive, or false. 7. I accept responsibility to do no harm to the physical, mental and emotional well-being of self, clients, and associates, and will comply with any self-reporting requirements. 8. I will refrain from engaging in behavior that may reasonably be interpreted as sexual conduct or sexual activities involving my clients. Before your first appointment with A Sensitive Touch, you will be asked to acknowledge by your signature that you have received and understand the Complementary and Alternative Health Care Client Bill of Rights. A current copy of this Bill of Rights, and a full listing of credentials will be available at all times online by going to. "THE STATE OF MINNESOTA HAS NOT ADOPTED ANY EDUCATIONAL AND TRAINING STANDARDS FOR UNLICENSED COMPLEMENTARY AND ALTERNATIVE HEALTH CARE PRACTITIONERS. THIS STATEMENT OF CREDENTIALS IS FOR INFORMATION PUR- POSES ONLY. Supervision: Two choices: If you have a supervisor, Include the following statement: If the Client has a complaint or concern about the care or services you have received, the Client may contact the Practitioner s supervisor: (Supervisor s name, business address, and telephone number). If you are in private practice, and are therefore your own supervisor, you skip the Supervisor section. Complaints: If the Client has a complaint or concern about the care or services they have received, the Client may also contact the Office of Unlicensed Complementary and Alternative Health Care Practice located in Minnesota Department of Health: Mailing address: P.O. Box 64882, St. Paul, MN Phone: Fax: Website: Fees, Payment, Insurance: The Practitioner's fees, the practitioner's method of billing for such fees, the names of any insurance companies that have agreed to reimburse the practitioner, or health maintenance organizations with whom the practitioner contracts to provide service, whether the practitioner accepts Medicare, medical assistance, or general assistance medical care, and whether the practitioner is willing to accept partial payment, or to waive payment, and in what circumstances; You can also include your office s cancellation policy here. See fictional CAP BOR below for an example. Change of Price: Clients have the right to reasonable notice of changes to the prices, services, or policies. Theory of Treatment: The state requires a Plain language summary of the theoretical approach used to provide service to clients. The Practitioner s Theory of Treatment is: Describe your Treatment approach. Right to Current Information: Clients have the right to complete and current information concerning the practitioner's assessment and recommended service that is to be provided, including the expected duration of the service to be provided. Right to Confidentiality: Client records are confidential and will not be released, unless authorized by the client in writing or as otherwise provided for by law. Right to Self Access: Clients have the right to access to their own records maintained by the Practitioner s office, in accordance with state statute sections to ; Personal Interaction: Clients have the right to expect courteous treatment, free from verbal, physical, or sexual abuse. Other Treatment Available: Other massage therapy services are available to the Client in this same community. These can be located by asking the Practitioner, the provider who referred you to this practitioner or the following practitioner database: Right of Agency: The Client has the right to choose freely among available practitioners and to change practitioners after services have begun, within the limits of health insurance, medical assistance, or other health programs Records Transfer: The Client have the right to coordinated transfer of your records when there will be a change in the provider of services Right of Refusal: The Client may refuse services or treatment, unless otherwise provided by law. Right of Nonretribution: The Client has the right to assert the any and all of above-mentioned rights without retaliation from the Practitioner. I acknowledge by my signature that I have received and understand the Complementary and Alternative Health Care Client Bill of Rights. Signature Date (print name)

4 REFERRAL FOR THERAPEUTIC MASSAGE AND BODYWORK Patient s Name: Today s Date: Referring Practitioner:Phone #: ( ) Referring Practitioner s Address: Date of Injury / Onset: / / History: Symptoms & Diagnosis (ICD-9) codes: Goals of prescription (i.e. pain relief, soft-tissue rehab, circulation enhancement, etc.): MODALITIES REQUESTED Please indicate which procedures you would like performed on the patient: Therapist s Discretion Range of Motion Stretching NeuroMuscular Re-education (includes CranioSacral Therapy, NeuroMeningeal techniques) Swedish Massage Techniques Manual Therapies (includes trigger point, acupressure, traction, connective tissue massage, etc.) KinesioTape application Other: TREATMENT FREQUENCY & DURATION 15 minute session 30 minute session 60 minute session Other: Number of sessions: sessions over the next weeks OR PRN Note: PRN referral is valid for one year. Practitioner s Signature: If submitting to an insurance company, please provide the following information: Name of Insurance Company: Adjuster:Phone: Address to send claims: Claim #:_Pre-approved? Massage therapy and other forms of bodywork can be considered adjunctive to primary medical care, chiropractic, and physical therapy. Massage therapy provides quality preventative, rehabilitative, and complementary health care with a medical referral.

5 FINANCIAL POLICY AGREEMENT Massage Therapy Charge Insurance Submission Today s Date: Client Name: Claim#: Date of Injury: Type (circle one): Auto Other Personal Injury Address where to send bill: Claim adjustor name: Phone #: Name of Insured: Insured DOB: This agreement is made between the above named client (herein referred to as CLIENT) and A Sensitive Touch (herein referred to as AST). In regards to billing CLIENT s insurance company related to approved massage therapy for a personal injury claim, AST agrees to: _ submit copies of bills to CLIENT s insurance company on a timely basis (current billed rate is $28.75 per 15 minute increment) _ submit copies of SOAP notes to CLIENT s insurance company _ submit copies of professional credentials to CLIENT s insurance company, should they be requested _ submit a letter of update to CLIENT s primary physician/practitioner at the end of each prescribed session _ provide CLIENT with summaries and/or copies of billing statements In regards to billing CLIENT s insurance company related to approved massage therapy for a personal injury claim, CLIENT agrees to: _ successfully keep all scheduled appointments _ give 24 hour notice should the appointment need to be changed _ pay AST any billed charge not paid for by CLIENT s insurance company Should CLIENT s insurance company discontinue benefits prior to CLIENT s full recovery, AND if CLIENT has a valid prescription for massage therapy on file, CLIENT agrees to: _ make payment in full for any sessions received after benefits have been discontinued. Same Day Pay Discounts will apply to only to sessions paid the same day as service. Payment plan arrangements may be made under agreement in writing by both parties. The two parties agree to the terms listed above. A copy will be provided for both parties. _ CLIENT A SENSITIVE TOUCH

6 CONSENSUAL LIEN FOR THERAPIST SERVICES & MEDICAL RECORDS RELEASE Insurance Company: Patient: Today s Date: Date of Birth: Date of Injury: I hereby authorize A Sensitive Touch to furnish you with medical records of his/her examination, diagnosis. treatment, prognosis, etc. of myself in regard to the accident of. I hereby authorize and direct you, my insurance company and/or my attorney, to pay directly to A Sensitive Touch such sums as may be due and owing for professional service rendered me both by reason of the accident of and by reason of any other bills for services and to withhold such sums from any settlement judgment or verdict as may be necessary to pay for these services. I hereby further give a lien on my case to A Sensitive Touch against any and all proceeds of any settlement, judgment or verdict which may be paid to you, my attorney, or myself as the result of the injuries for which I have been treated or injuries in connection therewith. I fully understand that I am directly and fully responsible to A Sensitive Touch for all professional bills, submitted by their office for services rendered me and that this Agreement is made solely for their additional protection and in consideration of their awaiting payment. I further understand my obligation to make payment is not contingent on any settlement, judgment or verdict by which may occur. Dated: Patient s Signature: Interpreter Name: Interpreter s Signature: WITNESS SIGNATURE AND ADDRESS Witness: Address: cc Attorney:

7 Injury Date: This questionnaire has been designed to give your health care provider information as to how your NECK pain has affected your ability to manage everyday life. Please answer every section and mark in each section only the ONE box which applies to you. I realize you may consider that two of the statements in any one section relate to you, but please just mark the box which most closely describes your problem today.

8 BACK PAIN AND DISABILITY QUESTIONNAIRE (Revised Oswestry) This questionnaire has been designed to give your health care provider information as to how your BACK pain has affected your ability to manage everyday life. Please answer every section and mark in each section only the ONE box which applies to you. I realize you may consider that two of the statements in any one section relate to you, but please just mark the box which most closely describes your problem today. Patient Name Injury Date: Today s Date: SECTION 1 PAIN INTENSITY? The pain comes and goes and is very mild.? The pain is mild and does not vary much.? The pain comes and goes and is moderate.? The pain is moderate and does not vary much.? The pain comes and goes and is severe.? The pain is severe and does not vary much. SECTION 6 STANDING? I can stand as long as I want without pain. Injury Date:? I have some pain on standing but it does not increase with time.? I cannot stand for longer than one hour without increasing pain.? I cannot stand for longer than ½ hour without increasing pain.? I cannot stand for longer than 10 minutes without increasing pain.? I avoid standing because it increases the pain straight away. SECTION 2 PERSONAL CARE? I would not have to change my way of washing or dressing in order to avoid pain.? I do not normally change my way of washing and dressing even though it causes some pain.? Washing and dressing increase the pain but I manage not to change my way of doing it.? Washing and dressing increase the pain and I find it necessary to change my way of doing it.? Because of the pain I am unable to do some washing and dressing.? Because of the pain I am unable to do any washing and dressing without help. SECTION 3 LIFTING? I can lift heavy weights without extra pain.? I can lift heavy weights but it causes extra pain.? Pain prevents me from lifting heavy weights off the floor.? Pain prevents me from lifting heavy weights off the floor, but I manage if they are conveniently positioned (e.g. on a table).? Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned.? I can only lift very light weights at the most. SECTION 4 WALKING? I have no pain on walking.? I have some pain on walking but it does not increase with distance.? I cannot walk more than 1 mile without increasing pain.? I cannot walk more than ½ mile without increasing pain.? I cannot walk more than ¼ mile without increasing pain.? I cannot walk at all without increasing pain. SECTION 5 SITTING? I can sit in any chair as long as I like.? I can only sit in my favorite chair as long as I like.? Pain prevents me from sitting more than 1 hour.? Pain prevents me from sitting more than ½ hour.? Pain prevents me from sitting more than 10 minutes.? I avoid sitting because it increases my pain right away. SECTION 7 SLEEPING? I get no pain in bed.? I get pain in bed but it does not prevent me from sleeping well.? Because of pain my normal night s sleep is reduced by less than ¼.? Because of pain my normal night s sleep is reduced by less than ½.? Because of pain my normal night s sleep is reduced by less than ¾.? Pain prevents me from sleeping at all. SECTION 8 SOCIAL LIFE? My social life is normal and gives me no pain.? My social life is normal but increases the degree of pain.? Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g. dancing, etc.? Pain has restricted my social life and I do not go out very often.? Pain has restricted my social life to my home.? I have hardly any social life because of the pain. SECTION 9 TRAVELING? I have no pain while traveling.? I have some pain while traveling but none of my usual forms of travel make it any worse.? I have extra pain while traveling but it does not compel me to seek alternate forms of travel.? I have extra pain while traveling that compels me to seek alternative forms of travel.? Pain restricts all forms of travel.? Pain prevents all forms of travel except that done lying down. SECTION 10 CHANGING DEGREE OF PAIN? My pain is rapidly getting better.? My pain fluctuates but overall is definitely getting better.? My pain seems to be getting better but improvement is slow at present.? My pain is neither getting better nor worse.? My pain is gradually worsening.? My pain is rapidly worsening.