Name _______________________________________________________
Street Address ________________________________________________ City__________________ State_____ Zip__________________________
Date of Birth _________________________________________________

Work Phone _______________________ Home phone_________________ Cell Phone/pager______________

Emergency Contact _____________________________________________

Employer ____________________________________________________
Social Security Number _________________________________________
Occupation __________________________________________________

Referring Physician:_____________________________________________ 
Primary Care Physician:__________________________________________

Insurance Information:

Was Injury a result of an accident?_________ If yes: Job related________
 Auto ________ Other_________

Date of Injury or onset: ________________________
Referring Physician_____________________________

Insurance Company Name:__________________________________________________________
Billing Address:__________________________________________________
Phone Number:__________________________________________________
Contact person/ case manager _______________________________________

Name of Insured :________________________________________________
Address:_______________________________________________________
Phone:_________________________________________________________

Group/Claim Number: ____________________________________________

Attorney (if applicable) 
Name :_______________________________________________________
Address:______________________________________________________
Phone number: _________________________________________________

I hereby authorize the release of medical information necessary to process my insurance claim. This may include intake forms, chart notes, reports, correspondences, billing statements and any other information to my attorneys, health care providers and insurance case managers.

I am responsible for all charges for all services provided. In the event that the insurance company denies benefits or makes a partial payment, I am responsible for any balance due. This may not apply to insurance companies that I am under contract with.

I understand the benefits and risks of massage and give my consent for massage. I will consult my practitioner with any questions or concerns immediately.

I have stated all medical conditions that I am aware of and will keep my practitioner informed of any changes.

I agree to provide 24 hour cancellation notice. If I fail to do so, I agree to pay the full appointment fee. (Please note that insurance companies do not pay this, you do.)

Signature ____________________________________________________
Date _______________________________________________________
 
 

Check any or all that apply to your present health:

___ headaches ___chronic pain ___varicose veins

___ vision problems ___muscle or joint pain ___blood clots

___ sinus problems ___numbness/tingling ___high/low blood pressure

___ jaw pain/teeth grinding ___sprains/strains ___diabetes

___ fatigue ___scoliosis ___cancer/tumors

___ depression ___arthritis ___infectious disease

___ sleep difficulties ___tendonitis ___skin problems

Women only: Pregnant___ Painful menstruation___ endometriosis___

Men only: Prostrate problems___

List all medications/herbs/vitamins and dosage: _____________________________________________________________

____________________________________________________________

List physical activities you participate in regularly____________________________________________________

Describe the events of the injury or accident: ____________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

List previous major injuries/surgeries: ___________________________________________________________

_________________________________________________________________________________________

What other treatments are you receiving and by whom (acupuncture, physical therapy, chiropractic, naturopathic): ______________________________________________________________________________

_________________________________________________________________________________________

What seems to help the most? ________________________________________________________________

What seems to aggravate the condition the most?_________________________________________________

What is your main activity at work? On phone ________ Sitting________ Computer work____________

Driving car_____________ Walking_____________ 
Other _______________________________________

What do you do to relieve stress______________________________________
______________________________________________________________

Practitioner Comments_____________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________
 
 

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