Health History Form v. 2017
       
When you are in pain you don't have to wait,
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520-320-1953

We are Tucson's leader in providing Massage Therapy, Acupuncture, Chiropractic Care, Stress Management, and Wellness Programs to help people feel better, create ease in their lives relieving their pain and supporting them toward optimum health and function. 
Winner of the 2014 Best Alternative Healing Center in Tucson!

Feel free to contact us with any questions. We are here to help!
Mara Concordia, CEO and Owner
Our 
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For your Safety:

For your Safety:

Please be aware that there are contraindications for receiving massage after drinking alcohol or under the influence of drugs and for your safety we reserve the right to refuse service to any individual who appears to be intoxicated.
Thank you, The Management 
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? If other, please explain

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




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.  What is your primary reason for your visit today? (*required):

12. What is your primary reason for your visit today? (*required):


13.  Which professional treatments have you received? Check all that apply

13. Which professional treatments have you received? Check all that apply


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

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


15.  How frequently? (*required)

15. How frequently? (*required)


16.  When was your last session?

16. When was your last session?


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

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


18.  If you could change anything with your health, what would you change?

18. If you could change anything with your health, what would you change?


19.  What will you be able to do again once those changes happen?

19. What will you be able to do again once those changes happen?


20.  What "other" changes would you like to see? Not health related.

20. What "other" changes would you like to see? Not health related.


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

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


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

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


23.  Current symptoms? Check all that apply

23. Current symptoms? Check all that apply


24.  Health History, check all that apply

24. Health History, check all that apply


25.  Health History, check all that apply

25. Health History, check all that apply


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

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


27.  Please list all allergies, or N/A

27. Please list all allergies, or N/A


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

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


29.  If you have pain or have been in an accident, please complete:

29. If you have pain or have been in an accident, please complete:

31.  Type of pain? Check all that apply

31. Type of pain? Check all that apply


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

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


33.  When did your symptoms begin?

33. When did your symptoms begin?


34.  How frequent are the symptoms?

34. How frequent are the symptoms?


35.  Does the problem interfere with:

35. Does the problem interfere with:


36.  Which movements create the pain?

36. Which movements create the pain?

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

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

38.  Type of accident?

38. Type of accident?


39.  Accident report filed with:

39. Accident report filed with:


40.  Attorney's name if applicable

40. Attorney's name if applicable


41.  Referring physician, if applicable

41. Referring physician, if applicable


42.  Date of last full physical?

42. Date of last full physical?


43.  Date of last X-ray

43. Date of last X-ray


44.  Date of last Blood tests

44. Date of last Blood tests


45.  Date of last MRI/CT/Bone scan

45. Date of last MRI/CT/Bone scan


46.  Date of last urine test

46. Date of last urine test


47.  AGREEMENT AND SIGNATURE

47. AGREEMENT AND SIGNATURE

BY SIGNING BELOW I ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND AND AGREE TO THE FOLLOWING:
  • I understand that the treatment can be terminated at any time be either myself or the therapist upon verbal request.
  • I understand that the L.M.T. does not diagnose illness or disease and does not prescribe medical treatment or pharmaceuticals, nor are spinal manipulations part of massage therapy. It is recommended I work with my PCP for any condition I may have. I have stated all known conditions and medications, and I will keep the L.M.T. updated on changes.
  • I hereby request and consent to the performance of therapeutic massage and acupuncture and other complementary and alternative medicine treatments as requested by the client/patient. (See chiropractic care)
  • 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 or their affiliates.
  • The Peaceful Spirit Massage Therapy and Chiropractic 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. All other services will be billed at current rate.
  • 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. 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 lien and my signature shall be considered effective and valid as original.

48.  Client or patient Signature

48. Client or patient Signature


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

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


50.  Chiropractic Care Informed Consent

50. 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.




51.  SIGNATURE

51. SIGNATURE


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

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


53.  Verifier

53. Verifier

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