Beth Ann's Therapeutic Massage: New Patient Form

First Name

Last Name

Date of Birth

Gender

Occupation

Mobile Phone

Home Phone

Work Phone

Source of Referral

Country

Province / State

Postal / Zip Code

Doctor's Name

Doctor's Phone

Doctor's Address

Please enter the Last 4 Digits of your Social Security Number:

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Do you have Appointment Preferences? If so What ?

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First Contact Name and Relationship

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First Contact Day Phone Number

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First Contact Night Phone Number

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Second Contact Name: and Relationship

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Second Contact Day Phone Number

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Second Contact Night Phone Number

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Third Contact Name and Relationship

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Third Contact Day Number

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Third Contact Night Number

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Fourth Contact Name and Relationship

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Fourth Contact Day Number

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Fourth Contact Night Number

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Stiff or Painful Joints

Spasms/cramps

Strains/sprains

Broken/fractured bones

Back pain

Spinal Issues

Disk Problems

Hip Pain

Hand pain

Arm pain

Shoulder Pain

Neck pain

Leg Pain

Foot Pain

Chest, ribs, abdominal pain

Weak or Sore Muscles

Problems walking

Jaw pain/TMJ

Tendinitis

Bursitis

Arthritis

Osteoporosis

Scoliosis

Bone or joint disease

Lupus

Other

Detailed Data for the above boxes

Dizziness

Shortness of breath or Fainting

Cold feet or hands or Cold sweats

Swollen ankles

Pressure sores

Varicose veins

Blood clots

Stroke

Heart condition

Irregular heart beat

Poor Circulation

Chest pain

Shortness of Breath

Sinus problems

Asthma

High blood pressure

Low blood pressure

Lymphedema

Other

Detailed Data for the above boxes

Rashes

Athlete's Foot

Warts

Moles

Acne

Eczema

Psoriasis

Ringworm

Fibromylalgia

Cosmetic surgery

Other

Detailed Data for the above boxes

Loss of Appetite

Eating Disorder

Nervous stomach

Abdominal Pain

Indigestion

Intestinal gas/bloating

Bowel Disfunction

Diarrhea

Diverticulitis

Constipation

Bladder/Kidney Disfunction

Irritable bowel syndrome

Crohn's Disease

Colitis

Adaptive aids

Other

Detailed Data for the above boxes

Siatica / Shooting Pain

Head Injuries/Concussions

Dizziness/RInging in the ears

Memory Loss/Confusion

Difficulty Concentrating

Numbness/tingling or Twitching of face

Fatigue

Chronic pain

Sleep disorders

Ulcers

Paralysis

Herpes/shingles

Cerebral Palsy

Epilepsy

Chronic Fatigue Syndrome

Multiple Sclerosis

Muscular Dystrophy

Parkinson's disease

Spinal cord injury

Depression

Other

Detailed Data for the above boxes

Pregnancy

PMS

Menopause

Pelvic Inflammatory Disease

Endometriosis

Fibrotic Cysts

Hysterectomy

Fertility concerns

Other

Detailed Data for the above boxes

Thyroid Disfunction

Diabetes Type 1

Diabetes Type 2

Pre-diabetes

Detailed Data for the above boxes

Please list all Surgeries, the date and if there is any associated pain, the pain level.

Most Resent:

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Scents please list

Oils, please list

Lotions, please list

Detergents

Seasonal

Other

Detailed Data for the above boxes

Drug use

Alcohol use

Nicotine use

Caffeine use

Hearing impaired

Visually impaired

Post/Polio Syndrome

Cancer Benign

Cancer - Malignant

HIV

RSV

SARs

RSS

Measels

German Measels

Mumps

Whooping Cough

Flu

COVID-19

Infectious disease / Infestations not listed above (please list)

Other congenital or acquired disabilities (please list)

Please list any additional comments regarding your health and well-being:

I have stated all conditions that I am aware of and this information is true and accurate. I will inform the health care provider of any changes in my status.

What Trimester are you in?

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How many Weeks Pregnant are you?

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How many Previous Pregnancies?

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I AM Exercising During My Pregnancy

I AM NOT Exercising During My Pregnancy

If yes to question, how often do you exercise per week, for what duration, and what types of exercise?

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Abdominal Cramping

Pre-term labor

Chronic Hypertension

Leaking amniotic fluid

Bladder infection

Blood clot or phlebitis

Problems with placenta

Uterine bleeding

Other

Are you experiencing a high risk pregnancy?

Yes

Please check this box if you are interested in using Massage Therapy to induce you. This is informational only until a script is received from your physician granting permission.

Care Team Contact Name(s) and Contact Number(s)

Have you ever had professional massage?

Yes

What Pressure Do you or Would you Prefer?

Light

Medium

Deep

Are there any areas (feet, face, abdomen, etc) you DO NOT want massaged?

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The therapist will address the areas required to bring you maximum relief in the time allotted. Are there any areas that you especially want treated?

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1. I authorize the use or disclosure of Protected Health Information (PHI) for the purpose indicated.

2. I have the right to revoke this authorization. To do so I understand I must submit my revocation in writing to Beth Ann's Therapeutic Massage.

3. The revocation will prevent further disclosure of my health information.

4. I also understand that a written revocation is not effective with respect to actions Beth Ann's Therapeutic Massage took in reliance on a valid Authorization, or where the Authorization was obtained as a condition of obtaining insurance coverage.

5. I am signing this authorization voluntarily and understand my entitlement to treatment, payment, enrollment, or eligibility for health plan benefits will not be affected if I do not sign this HIPAA Authorization Form.

6. I have a right to receive a copy of this HIPAA Authorization Form.

I give my Permission to Beth Ann's Therapeutic Massage to release medical information to the following persons or organizations.

My signature authorizes and directs payments of medical benefits for services billed to my health care provider: Beth Ann's Therapeutic Massage.

It is my Responsibility to pay for all services provided. In the unfortunate event that my insurance company denies payment or makes a partial payment, I am responsible for the balance.

If Beth Ann's Therapeutic Massage has contracted with my insurance company at a discount rate and the agreed-upon fee has been satisfied, the balance will be waived

First Emergency Contact

Second Emergency Contact

Third Emergency Contact

Fourth Emergency Contact

I am a Veteran. I release my Information to the VA.

Physician / Chiropractor

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Physician / Chiropractor

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Physician / Chiropractor

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Legal Representation

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Insurance Adjuster

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Other People

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Other Organizations

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Please accept this release as authorization to discuss my medical case with the person(s) listed above and to offer them my medical files as deemed necessary for my health.

Please remove all loose articles of clothing and jewelry

Your therapist will drape your body appropriately with a sheet and blanket; and ensure the room temperature and table temperature match your preferred preference

We encourage you to give your therapist feedback with regards to the pressure applied to your body during your massage.

We strongly encourage you to point out any pain points or ticklish areas on your body.

At any time during your consultation or during your massage, please feel free to ask questions. This session is about you, your body, and your health

It is important to know massage may not be appropriate with certain medical conditions or for injuries to specific body parts.

If, during the session, you feel any pain or discomfort, it is highly recommended for you to notify your therapist so that treatment can be adjusted immediately.

Massage is not a substitute for medical examination, diagnosis, or treatment. It is recommended that you seek the attention of a qualified medical professional for any mental or physical conditions that require such attention.

Massage therapy is not a substitute for care such as spinal or skeletal adjustments; therefore, if you require such treatment, it is recommended you consult with a qualified medical professional such as a chiropractor.

It is important that you keep your therapist current on any changes in your medical conditions as massage is not appropriate under certain circumstances.

By signing this form and going through our intake process, you affirm that you have answered all questions honestly

There is no liability on the therapist in the case you do not disclose any conditions or update him or her with regards to changes in your medical condition that might impact your reason to receive massage.

Beth Ann's Therapeutic Massage and its therapists are professional complementary healthcare providers, any comments, suggestions, or solicitation of sexual behavior is grounds for immediate termination of your session without refund

I promise to participate fully as a member of my health care team.

I will make sound choices regarding my treatment plan based on the information provided by my Massage Therapist and other members of my health-care team.

I agree to participate in the self-care program we select.

It is my choice to receive manual therapy

I give my consent to receive treatment

I have reported all health conditions that I am aware of and will inform my practitioner of any changes in my health.

We will ask you to sign and date a form on your first visit. Please Print your name below.

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Beth Ann's Therapeutic Massage: New Patient Form

Section A

Section B

Please enter your emergency contact information. One emergency contact is highly recommended, others are optional.

Section C

Section C-1

Pregnancy specific medical questions.

Section D

The next section is your medication list.

FIRST please list all Prescription Medications, Dose and Time of Day Taken.

NEXT list all your OTC (Over-the-Counter) Medications, Dose and Time of Day Taken.

Third list all your Vitamins and Supplements, Dose and Time of Day Taken.

Section E

AUTHORIZATION for the RELEASE of PROTECTED HEALTH INFORMATION

AUTHORIZATION for the ASSIGNMENT of BENEFITS

AUTHORIZATION of FINANCIAL RESPONSIBILITY

Unless otherwise revoked by me in writing, this authorization for the release of my PHI to the following individuals/organizations will expire 1 year from the date above. (Labeled "Today's Date")

This is your PHI Information Release Form.

Start with the check boxes.

CONSENT to TREATMENT

By Checking each of the following statement boxes: