Confidential Health History Questionnaire

Name______D.O.B.______

Address______Claim/ID#______

______

Phone Cell ______WK______HM______

Email______Do you wish to receive mailings?___Yes___No

Referred by______

What brings you to MassageCraft & clinic today? ______Have you ever had bodywork before? Yes/No. What kinds? ______For what conditions? ______What is your favorite part of a session? ______Your least favorite part?______What do you do for pleasure?______What physical activities do you enjoy? How often?______Are there activities, work or recreational that you are unable to do due to a particular condition?______How long has this persisted?______Has it been diagnosed?______Is there anything about your diet or lifestyle you would like to change?______Have you ever had a musculoskeletal or injury? Please circle: Sprain Tear Tendonitis Broken bone Work injury Sports injury Accident Tension Please explain______

Please fill-in areas of pain and note on a scale of 1-10 What makes it worse?______What makes it better?______Do you sleep well?______What position are you most comfortable in?______Headaches? Yes/No. Describe______Your Physician______Allergies?______Do I have permission to contact him or her?_____ List medications______Signature______Date______

ACUPUNCTURE CONSENT FORM I, ______, voluntarily consent to be treated with acupuncture by ______.

I understand that acupuncture involves the following The insertion of sterile disposable needles through the skin, with or without electrical stimulation. Moxabustion, the application of heat to acupuncture points. techniques such as , , or zero balancing. Cupping, either static or moving. The skin is marked for 3-4 days. , a scraping technique, which marks the skin for up to 3-4 days. Blood letting, which involves the use of a lancet to extract tiny drops of blood form acupuncture points. I will inform my practitioner about any circulatory or clotting disorders or use of blood thinners. Cupping and gua sha should not be done under these circumstances.

I understand that it is important to have eaten before treatment. It is not advisable to receive treatment if extremely hungry, weak, or intoxicated.

I have been informed that although rare, certain side-affects may result from my acupuncture treatment. These could include some minor discomfort, localized bruising, temporary aggravation of pre-existing conditions, fainting, diarrhea, and nausea.

CANCELLATION POLICY I agree to pay MassageCraft in full if I fail to cancel my appointment within 24 hours. This includes insurance clients. MassageCraft cannot bill insurance for services not rendered. Initials____

INSURANCE COVERAGE I understand that if MassageCraft bills my insurer for services rendered that I am responsible for any unpaid balance including co-pays and charges applied to my deductible, (Workers Compensation claims excepted.) Initials____ I authorize insurance payments of medical benefits to MassageCraft INC. Initials____ Your insurance company may require medical reports documenting your treatment and progress. Your initials authorize release of medical information necessary to process your claim. Initials____

By signing below I understand and abide by the above policies and procedures.

Signature______Date ___/___/___