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Massage Questionnaire

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					                           Massage Questionnaire
Please complete this questionnaire before your first appointment and submit it to Massage Therapy. We
require that this form be submitted several days prior to your initial visit. In order to address your
individual needs, the therapist will review your questionnaire before the appointment. This information
will remain confidential and is kept in a locked file in the Massage Therapy office, accessible only to the
therapists and RFC staff.

All payments for on-site Massage Therapy are through payroll deduction only. Fees will not be
deducted until the day of the massage. SAS benefit plans cover massage therapy when deemed a
medical necessity by an eligible health care provider. In order to qualify for insurance coverage, an
employee must submit a referral from an eligible health care provider before claims can be reimbursed.
The PPO Plan or Indemnity Plan may request that the medical referral be renewed at least annually.

Please contact the SAS Benefits department directly for questions on coverage.

Name _______________________ Date _____________________ DOB ________________
Home Phone ( ) —                         Work Phone ( )       —
Height _______ Weight ___________
Occupation _______________
Name of Employee ______________
Affiliated With ___________________
Have you been under the care of a health care provider (chiropractor, physician, psychotherapist,
alternative practitioner) in the past year? No ❒ Yes ❒ - for treatment of
________________________________________________________________
Practitioner’s
name__________________________________________________________________________

Health history. Please check all conditions you have experienced in the last five years.
❒ tuberculosis ❒ anemia ❒ asthma
❒ heart disease ❒ emphysema ❒ poliomyelitis
❒ arthritis ❒ severe depression ❒ cancer
❒ overweight ❒ diverticulitis ❒ nephritis or kidney disease
❒ hernia or rupture ❒ hypoglycemia ❒ migraine headaches
❒ paralysis ❒ ulcers ❒ diabetes
❒ arteriosclerosis ❒ liver disorder ❒ goiter or thyroid problem
❒ lymph node removal or biopsy
(specify/dates)_________________________________________________
❒ surgery (specify/dates)
___________________________________________________________________
❒ other (specify/dates)
_____________________________________________________________________
Describe any significant bodily injuries and the date of occurrence (i.e., accidents, sprains, falls, bone
fractures,
physical abuse, or other events):
________________________________________________________________
Have you ever been hospitalized? No ❒ Yes ❒
(describe/dates)_____________________________________

Are you pregnant or have any current medical conditions not listed above? No ❒ Yes ❒ (describe)
_______________________________

Please shade areas in the figures below which correspond to any joint or muscle pain you have been
experiencing:




PLEASE READ AND SIGN THE FOLLOWING
I have completed the information above and have listed all known medical conditions and physical
limitations. I will inform the massage practitioner of any changes in my physical health, medications,
treatments, recent injuries, open wounds, skin conditions, or areas of concern before each massage
session. I understand that massage is not a replacement for medical care or diagnosis and take
responsibility for consulting a qualified healthcare provider for any physical ailments.
I hereby acknowledge that all appointments, rescheduling requests and cancellations must be made by
calling and agree to pay for all scheduled appointments that I am unable to keep unless I leave a
message at least 24 hours in advance.


Signature                                              Date

________________________________________________________________________________

				
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posted:1/19/2011
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