Health History 2014
Secure Connection
Questions • Receipt
1.  Peaceful Spirit Massage & Wellness Centers health History Form

1. Peaceful Spirit Massage & Wellness Centers health History Form

2.  Legal Home Address

2. Legal Home Address

First Name*

Last Name*

Address*


City*

State*
Postal Code*

Country*
E-Mail*

Day Phone*

4.  If you checked referral, whom may we thank?

4. If you checked referral, whom may we thank?




5.  Date of Birth: Please include month, day and year, thank you

5. Date of Birth: Please include month, day and year, thank you


7.  Hobbies or favorite exercise or sports

7. Hobbies or favorite exercise or sports


8.  What type of work do you do?

8. What type of work do you do?


9.  Employer Name

9. Employer Name


10.  Employer phone number

10. Employer phone number


11.  Please list all repetitive movements you do (*required):

11. Please list all repetitive movements you do (*required):


12.  Which treatments have you received? Check all that apply

12. Which treatments have you received? Check all that apply


13.  Which type do you receive most frequently? (*required)

13. Which type do you receive most frequently? (*required)


14.  How frequently? (*required)

14. How frequently? (*required)


15.  When was your last session?

15. When was your last session?


16.  What do you receive treatments for? (*required)

16. What do you receive treatments for? (*required)


17.  Specifically for today's session, what is your desired outcome?

17. Specifically for today's session, what is your desired outcome?


18.  What are your current health goals?

18. What are your current health goals?


19.  How can we assist you in achieving your health goals?

19. How can we assist you in achieving your health goals?


20.  Are you currently receiving medical care? (*required)

20. Are you currently receiving medical care? (*required)


21.  If yes, for what condition are you under care?

21. If yes, for what condition are you under care?


22.  Current symptoms? Check all that apply

22. Current symptoms? Check all that apply


23.  Health History, check all that apply

23. Health History, check all that apply


24.  Health History, check all that apply

24. Health History, check all that apply


25.  List: Surgeries, Head Injuries, Broken Bones, Serious Falls or N/A

25. List: Surgeries, Head Injuries, Broken Bones, Serious Falls or N/A


26.  Please list all allergies, or N/A

26. Please list all allergies, or N/A


27.  Please list all medications, vitamins & supplements or N/A

27. Please list all medications, vitamins & supplements or N/A


28.  Regarding Today's Visit Complete The Following:

28. Regarding Today's Visit Complete The Following:

29.  When did your symptoms begin?

29. When did your symptoms begin?


30.  How frequent are the symptoms?

30. How frequent are the symptoms?


32.  Is the pain constant or does it come and go?

32. Is the pain constant or does it come and go?


33.  Does the problem interfere with:

33. Does the problem interfere with:


34.  Type of pain? Check all that apply

34. Type of pain? Check all that apply


35.  Which movements create the pain?

35. Which movements create the pain?

36.  If your condition is related to an accident complete:

36. If your condition is related to an accident complete:

37.  Type of accident?

37. Type of accident?


38.  Accident report filed with:

38. Accident report filed with:


39.  Attorney's name if applicable

39. Attorney's name if applicable


40.  Referring physician, if applicable

40. Referring physician, if applicable


41.  Date of last full physical?

41. Date of last full physical?


42.  Date of last X-ray

42. Date of last X-ray


43.  Date of last Blood tests

43. Date of last Blood tests


44.  Date of last MRI/CT/Bone scan

44. Date of last MRI/CT/Bone scan


45.  Date of last urine test

45. Date of last urine test


46.  Insurance Billing Information

46. Insurance Billing Information

47.  Name of Insurance Company:

47. Name of Insurance Company:


48.  Member ID#

48. Member ID#


49.  Who is responsible for this account?

49. Who is responsible for this account?


50.  Relationship to patient?

50. Relationship to patient?


52.  Insurance Subscriber's Name

52. Insurance Subscriber's Name


53.  Relationship to patient?

53. Relationship to patient?


54.  Subscriber's Date of Birth:

54. Subscriber's Date of Birth:


55.  Subscriber's Social Security Number:

55. Subscriber's Social Security Number:


56.  AGREEMENT AND SIGNATURE

56. AGREEMENT AND SIGNATURE

BY SIGNING BELOW I ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND AND AGREE TO THE FOLLOWING:
I understand that all fees are due at time of treatment, unless prior arrangements have been approved. I understand that I am
responsible for all collection costs, interest and appropriate legal fees for the collection of any unpaid debts to Peaceful Spirit.
The Peaceful Spirit cancellation policy is as follows: 24 hours notice of cancellation must be given or I will be billed $20 for a
missed one-hour or shorter appointment or $50 for a two hour or longer appointment. In addition, I acknowledge that I have received a copy of the applicable privacy policies. 
ASSIGNMENT AND RELEASE
Peaceful Spirit Therapeutic Massage Center LLC is pleased to file an insurance claim (in pre-approved cases) for you in the case
of personal injury, worker's compensation or health insurance where applicable. Please understand that the benefit contract is an agreement
between you and the insurance company (or your employer or at fault party's insurance company), and that verification of
benefits is not a guarantee of payment. You are fully responsible for any and all services rendered to you. All reasonable efforts
will be made to collect sums due from the insurance companies that are contractually obligated. If you receive a payment from
the insurance company, this payment must be brought into the office and shall be applied to the balance due.
I assign directly to Peaceful Spirit Therapeutic Massage Center LLC, or it's divisions all insurance benefits, if any, otherwise
payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by
insurance, even if prior authorization was granted. I acknowledge receipt of Notice of Privacy Practices sent under separate
cover. I hereby authorize Peaceful Spirit Therapeutic Massage Center LLC, or it's divisions to release all information necessary to
secure the payment of benefits. I authorize the use of this signature on all submissions. A photo copy of the assignment and my
signature shall be considered effective and valid as original.
57.  Client or patient Signature

57. Client or patient Signature


58.  Parent or guardian signature for children/dependents or enter N/A

58. Parent or guardian signature for children/dependents or enter N/A


59.  Chiropractic Care Informed Consent

59. Chiropractic Care Informed Consent

If you are currently scheduled with our chiropractor or plan to become a chiropractic patient in the future, please complete this section.


Dear Patient:

Please feel free to discuss any questions or concerns with the Doctor before signing

this consent.

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic

procedures, including various modes of physical therapy and diagnostic x-rays, on me (or the patient

named below, for whom I am legally responsible) by the doctor of chiropractic named above.

I have had the opportunity to discuss with the doctor and/or with other clinic personnel the purpose

and benefits of the chiropractic adjustment and other treatments outlined below. Alternatives to

treatment have been reviewed.

Though chiropractic adjustments and treatments are usually beneficial and rarely cause any problem,

I understand and informed that there are some risks to treatment. Risks include, but are not limited

to, sprains, fractures, dislocations, disc injury and stroke.

I understand that I will be receiving the following treatment:

Chiropractic adjustments (manually, or by adjusting instruments)

Electric muscle stimulation

Ultrasound

Myotherapy-soft tissue therapies

X-Ray

Rehabilitative Exercise


I understand that chiropractic, like any other form of health care, is not an exact science and that,

therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or

assurance has been made by anyone regarding the chiropractic treatment that I have requested and

authorized. I have had the opportunity to read this form and ask questions. Any question that I have

had regarding my care has been answered to my satisfaction. I consent to the proposed treatment.

PLEASE ENTER YOUR FULL NAME BELOW TO CONFIRM YOUR CONSENT FOR CHIROPRACTIC TREATMENT, THANK YOU.




60.  SIGNATURE

60. SIGNATURE


61.  Parent or guardian signature for children/dependents or enter N/A

61. Parent or guardian signature for children/dependents or enter N/A


62.  Verifier

62. Verifier

For security purposes, we ask that you enter the security code that is shown in the graphic. Please enter the code exactly as it is shown in the graphic.
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Testimonial:


This place has it all! Wonderfully skilled massage therapist who are attentative to specific needs of each individual client & other wellness options to support overall wellness all in one place!

-Bernadette M.

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