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First and last name*
Mobile number*
Email address*
Practitioner/Clinic Name:*
Contact Information:*
Client Name:*
Date:*
Preferred phone number:*
Best time to call:*
Email address:*
Preferred form of communication:*
How did you hear about me? (referral, Facebook, etc.)*
Is this a gift certificate?*
Yes
No
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?
Best times for massage:*
Communication Checklist (Pt. 1)
Fees/forms of payment
Cancellation/No-show policy
Late arrival policy
Confidentiality
Have you had a fever in the last 24 hours of 100°F or above?*
Yes
No
Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath*
Yes
No
Do you now, or have you recently had, any chills, muscle aches, new loss of taste or smell, or new rashes or lesions?*
Yes
No
Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?*
Yes
No
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*