Medical Client Intake Form by ula13878

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									                                                                Medical Client Intake Form


Name:                                                                         Today’s Date:
Address:                                         City:                        State:        Zip:
Home #: (      )                     Work #: (       )                        Cell #:(     )


E-mail:                                              Occupation:                               Date of Birth:


Emergency Contact & relationship to self:                                              Phone #: (     )
General & Medical Information – Please check all that apply and note the approximate date of occurrence.
  Abdominal Pain                    Accident – Date:
                                                                   Is there anything else that your therapist
  Arthritis                         Broken Bones
  Cancer – Type:                    Decrease Range of Motion       needs to be aware of?  No  Yes,
      Current treatment:            Disk Problem
                                                                   explain:
  Diabetes                          High Blood Pressure
  Heart Problems                    Low Back Pain
  Joint Ache                        Neck Pain
  Mid Back Pain                     Osteoporosis
  Nervous Tension                   Stiffness
  Sprains                           Surgery
  Stroke                            Varicose Veins
  Upper Back Pain                   Pregnant
  Whiplash                          Stabbing Pain
  Numbness                          Headache
  Contagious Disease                Stress
  Easily Bruised                    Medication – Type:
  Soreness                          Seizures
  Allergies:                        Other:


I understand the benefits and risks of massage and give my consent for massage. I will consult my practioner
with any questions or concerns immediately. I understand that massage practitioners do not diagnose illness,
disease, or any physical or mental disorder. I acknowledge that massage is not a substitute for medical
examination or diagnosis. I have stated all medical conditions that I am aware of and will update the massage
practitioner of any changes in my health status prior to future massage.
SIGNATURE:_________________________________________________DATE:___________________
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
insurance case provider, attorney and health care providers.
SIGNATURE:_________________________________________________DATE:___________________


                                            Financial Agreement
 I ________________________________________ acknowledge that I am responsible for full payment of my
 account. The Massage Place will attempt to secure payment from my insurer. If my insurer issues partial
 payment or denies my claim I will pay the balance of my account to The Massage Place. If I do not call 24
 hours before my scheduled appointment to cancel, then I am responsible for paying The Massage Place for
 the missed appointment and this missed appointment will not be billed to my insurance.
 SIGNATURE:_________________________________________________DATE:___________________
                                                               Insurance Information
                                   PIP Insurance Coverage Information

Patient’s Name:                                                      Social Security #:

Referring Doctor:                                             Doctor’s Phone #:

Date of motor vehicle accident:                        State where injury occurred:

                                                              Insurance Claim Adjuster/Contact:
Insurance Company:                                       Name:
Claim Number:                                            Address:
Phone Number:


       Attorney (if applicable) Name:

                             Address:



                             Phone: (     )



SIGNATURE:_________________________________________________DATE:___________________



__________________________________________________________________________________________
__________________________________________________________________________________________



                           Department of L&I Insurance Coverage Information

Patient’s Name:                                                      Social Security #:

Referring Doctor:                                             Doctor’s Phone #:

Date of Incident:

       Employer’s Name:

       Claim #:

       Claims Rep Name:                                       Phone#:

       Are you missing work because of this injury?
SIGNATURE:_________________________________________________DATE:___________________
                                                                         Injury Intake Form
                                     Client Name:                               Claim #:

How did the accident occur? Auto                  On-the-job                Other

Describe in detail the incident that resulted in the injury:




List all symptoms immediately post injury and rate their intensity “mild”, “moderate”, or “severe”:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

___

Are your symptoms  getting better           getting worse        no change since the date of injury.

What makes them better?




What makes them worse?




Describe any pain you are currently experiencing; e.g. sharp, dull, achy, tender, hot, etc. and where the

pain is on your body:




List all therapies/medications received for this injury: Chiropractor  Physical Therapy Acupuncture

 Pain Medication, type:                             Other, please explain:

What regular activities of daily living are affected by this injury?




What is your main activity at work? On phone  Sitting  Computer work  Driving  Walking

 Lifting  Other, please explain:
What regular work related activities are affected by this injury?




What do you want to get out of your treatment(s)?




Are there other comments or information that you would like to share concerning your accident or

physical injury?




SIGNATURE:_________________________________________________DATE:___________________

                                                                     Functional Rating Index

Name:                                                                       Claim #:

Today’s Date:                          Current Time:                         Treatment #:

In order to properly assess your condition, we must understand how much your injury is affecting your ability to
manage everyday activities. This functional rating index is based on your pain, it is not compared to anyone
else’s ratings. You will be asked to complete a Functional Rating Index before your 1st and last treatment of
your referral. For each item, please circle the number which most closely describes your condition right now.


                                             Overall Pain Level:
        0                      1                     2                         3                      4

    No Pain              Mild Pain              Moderate Pain             Severe Pain         Worst possible pain


                                     Amount of Pain throughout the Day:
        0                  1                       2                           3                      4
                    Occasional pain;     Intermittent pain: 50% of    Frequent pain; 75%        Constant pain;
    No pain
                    25% of the day                the day                 of the day           100% of the day

                                                Activity Level:
        0                      1                       2                       3                      4
  Can do all                                     Can do some                                    Cannot do any
                   Can do most activities                             Can do few activities
  activities                                      activities                                      activities
                                                  Sleep Level:
       0                    1                           2                       3                   4
                                                   Moderately           Greatly disturbed   Totally disturbed
 Perfect sleep    Mildly disturbed sleep
                                                 disturbed sleep              sleep               sleep

                                               Restriction Level:
       0                    1                          2                       3                   4

  No Pain; no         Mild Pain; no           Moderate Pain; need   Moderate Pain; need     Severe pain; need
  restrictions         restrictions              to go slowly        some assistance        100% assistance


                                            Pain Level while Driving:
       0                    1                          2                       3                   4

No Pain on long                                Moderate Pain on         Moderate pain on     Severe pain on
                  Mild Pain on long trips
     trips                                        long trips              short trips          short trips


                                                   Page 1 of 2
                                           Pain Level while Working:
            0                       1                       2                       3                     4

Can do usual work plus     Can do usual work;         Can do 50% of          Can do 25% of
                                                                                                  Cannot work
 unlimited extra work        no extra work             usual work             usual work



                                            Pain Level while Lifting:
        0                    1                         2                        3                     4

No pain with heavy   Increase pain with       Increased pain with       Increase pain with    Increase pain with
      weight           heavy weight            moderate weight             light weight           any weight


                                           Pain Level while Walking:
        0                    1                         2                        3                     4

No pain; can walk    Increase pain after      Increase pain after ½     Increase pain after   Increased pain with
  any distance             1 mile                     mile                    ¼ mile              any walking


                                           Pain Level while Standing:
        0                    1                         2                        3                     4

  No pain after      Increase pain after      Increase pain after 1     Increase pain after   Increase pain with
  several hours        several hours                  hour                    ½ hour             any standing
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