Emergency contact
Doctor
AREA OF COMPLAINT
Left side of neck
Comment
Right side of neck
Left side of upper back
Right side of upper back
Left side of mid back
Right side of mid back
Left side of low back
Right side of low back
Chest
Abdomen
Left arn
Right arm
Left shoulder
Right shoulder
Left elbow
Right elbow
Left wrist
Right wrist
Left hand
Right hand
Left leg
Right leg
Left hip
Right hip
Left knee
Right knee
Left ankle
Right ankle
Left foot
Right foot
HEADACHES
Migraines
Headaches
Cluster
Rebound
Sinus
Chronic daily headache
Tension
NEUROLOGICAL
Tingling
Multiple sclerosis
Brain injury
Stabbing
CVA
Sciatic pain
Loss of sensation
Seizure disorder
TIA
Vertebral or spinal cord injury
Epilepsy
Shingles
CP
Huntington disease
Dizziness
Parkinsons
Brain disorder
Numbness
Burning
Herniated disc
Chronic pain disorder
CARDIOVASCULAR
Congenital heart defect
Varicose veins
Heart attack
Blood pressure
Acute coronary syndrome
Coronary artery disease
Blood clots
Phlebitis
Aneurysm
Hyperlipedemia
CVA
Angina
Pericarditis
Pacemaker
Atherosclerosis
Raynaud’s disease
Cold hands
Heart disease
cardiac arrhythmia
rheumatic heart disease
high blood pressure
cold feet
chronic ischemic heart disease
valve disorders
low blood pressure
chronic CVI
MI
CHF
REPRODUCTIVE
Menstrual cycle disorder
Ovarian cyst/tumor
PID
Premenstrual syndrome
pregnancy
uterine disorder
gynacological conditions
breast disorder
ectopic pregnancy
edometriosis
menopause
IMMUNE
Non-Hodgkin lymphomas
RA
anaphylaxis
allergies
lupus
hodgkin lymphoma
infectious mononucleosis
cancer
leukemia
MUSCULOSKELETAL
hereditary/congenital deformity
strain/sprain
joint injury
amyotrophic lateral sclerosis (ALS)
Osgood-Schlatter disease
Osteoporosis
Muscular dystrophy
OA
Ankylosing spondylitis
gout
osteomalacia
Myasthenia gravis
tendonitis/bursitis
bone disease
Paget disease
sinus problems
compartment syndrome
psoriatic arthritis
artificial joints/special equipment
dislocation
scleroderma
fibromyalgia
fracture
arthritis
jaw pain TMJD
scoliosis
GASTROINTESTINAL
constipation
digestive conditions
poor appetite
diarrhea
stomach disorder
Crohn’s disease
diverticulitis
ulcerative colitis
eating disorder
esophageal disorder
fecal impaction
intestinal polyps
celiac disease
IBS
BLOOD
hypercoagulability
hepatitis
polycythemia
haemophilia
HIV
thromobis/embolism
high cholesterol
anemia
bleeding disorder
HIV/AIDS
SKIN
acne
athlete’s foot
psoriasis
allergic dermatosis
rash
bruise easily
herpes
hypersensitive reaction
rosacea
chemical burn
UV burn
hypersensitive reactions
melanoma/carcinoma
skin conditions
infectious skin conditions
pigmentary disorder
skin irritations
plantar wart
RESPIRATORY
chronic cough
respiratory conditions
shortness of breath
asthma
TB
emphysema
bronchitis
respiratory tract infection
COPD
cystic fibrosis
infectious respiratory conditions
HEARING
conductive hearing loss
Meniere disease
motion sickness
tinnitus
ear problems
vertigo
hearing loss
KIDNEY
renal cysts
urinary incontinence
UTI
bladder disorder
chronic kidney disease
congenital kidney disease
electrolyte imbalance
kidney stones
ENDOCRINE
acute pancreatitis
diabetes
hyperthyroidism
hypothyroidism
pituitary and growth disorder
prostate condition
FAMILY HISTORY
arthritis
cardiovascular
respiratory
MISCELLANEOUS
vision problems
vision loss
mental health issues
surgical pins or wires
insomnia
other medical conditions
other diagnosed diseases
MEDICATIONS
INJURIES
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Consent for sensitive area assessment and treatment
consent for assessment and treatment of sensitive areas
When the treatment of sensitive areas is indicated during the course of a massage therapy treatment plan, it is important that you fully understand the nature and purpose of that treatment. In addition to our discussion about the treatment and area at the time of recommendation, this written consent form will act as a record of that discussion. If you have any questions, either during our discussion or while completing this form, please do not hesitate to ask.
During this discussion, the benefits, risks and side effects, areas to be treated, positioning and draping (covering) to be used have been explained to me.
— The clinical reasons(s) for assessment of an area(s) and the draping methods to be used
— The expected benefits of the assessment
— The potential risks of the assessment
— The potential side effects of the assessment
— That consent is voluntary
— That I can withdraw or alter my consent at any time. I voluntarily give my informed consent for the assessment and/or treatment as discussed and outlined above.
I will always have the opportunity to ask questions about the above information, and I also understand that I can alter or withdraw my consent for this treatment and/or treatment plan at any time. A record of this consent will be kept in my client file held by Muscle Mechanic LLC.
It is with the above understanding that I, [name], consent to the treatment of the sensitive areas as indicated.
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Payment Policy
Payment Agreement
Before we begin services, please sign below indicating you have read, understand and agree to the following payment policies.
— You agree to be financially responsible for all charges regardless of any applicable insurance or benefits, third-party interest, or the resolution of any legal action or lawsuits in which you may be involved.
— Payment is expected at time of service unless you have made other payment arrangements with us.
Use of Health Savings Accounts (HSA). We will provide you with a receipt for the services that you can, at your discretion, submit to your HSA plan in accordance with your HSA plan rules. You are responsible for complying with HSA rules when determining whether the services you purchase from us can be paid from an HSA account.
Use of Health Reimbursement Arrangement (HRA) or Flexible Spending Account (FSA). An HRA and FSA will only reimburse for actual services received (not pre-paid services). Therefore, if you purchase a discounted pre-paid package plan and want your HRA or FSA to reimburse you, we will provide you with a receipt that you can submit for reimbursement after you have used your entire package. Upon request, we will also provide a receipt for visits used to date that you can, at your discretion and in accordance with your HRA or FSA rules, submit for reimbursement. Please note that HRA and FSA plans have rules about what services qualify for reimbursement. You are responsible for complying with your HRA and/or FSA plan rules when determining whether the services you purchase qualify for reimbursement.
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Cancellation Policy
2-hour advance notice is required when cancelling your appointment. If you are unable to cancel a minimum of 2 hours prior to your appointment, you could be charged 25% of your session fee at the discretion of Muscle Mechanic LLC. This amount must be paid prior to your next scheduled appointment.
No shows. The full amount of your session may be charged to your account at the discretion of Muscle Mechanic LLC. This amount must be paid prior to the next scheduled appointment. If there is credit remaining on your account (pre-paid sessions, gift certificates, etc.), the full amount of that session will be removed from your account.
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Massage Therapy Consent
–It is my choice to receive massage therapy.
–I am aware of the benefits and risks of massage and give my consent for massage.
–I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments.
–I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis.
–I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.
–I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law.
–I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment.
I, [name], will openly and honestly communicate with my therapist at all times. I have read over the intake and have answered the questions honestly and to the best of my abilities.