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 & Acupuncture 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. Massage techniques such as tui na, shiatsu, or zero balancing. Cupping, either static or moving. The skin is marked for 3-4 days. Gua sha, 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 ___/___/___ .