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? __________________