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First and last name

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Mobile number

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Email address

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Contact Information:

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Client Name:

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Date:

Preferred phone number:

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Best time to call:

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Email address:

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Preferred form of communication:

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How did you hear about me? (referral, Facebook, etc.)

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Is this a gift certificate?

Yes

Have you had a massage/bodywork before?

Yes

Frequency:

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Types of massage/bodywork received:

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Preferred types of massage:

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Reasons for seeking massage? (relaxation, injury, etc.)

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Description of injury/health condition:

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Possible complications/medications:

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Expected outcomes (functional improvement, symptom relief, wellness):

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Typical activities of daily living (affected by condition?):

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Occupation (affected by condition?):

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Are you seeking insurance reimbursement?

Yes

Car collision/personal injury?

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On-the -job injury

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Private health insurance?

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Do you have a physician referral with diagnosis codes?

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Best times for massage:

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Communication Checklist (Pt. 1)

Fees/forms of payment

Cancellation/No-show policy

Late arrival policy

Confidentiality

Communication Checklist (Pt. 2)

Parking/directions

Work setting

Clothing/shiatsu

Communication Checklist (Pt. 3)

Modesty/Nonsexual/draping

Food/drugs/alcohol

Oils/lotions/allergies

Have you had a fever in the last 24 hours of 100°F or above?

Yes

Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath

Yes

Do you now, or have you recently had, any chills, muscle aches, new loss of taste or smell, or new rashes or lesions?

Yes

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

Do you have special needs I should prepare for:

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Do you have any questions or concerns:

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If out-call, ask for directions, parking, or special instructions:

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Packet Checklist

Health Information

Health Status Report

Billing Information

Directions/map

Date sent

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Awaken Your Senses & Knead "The Works" Massage LLC