Discounts and Offers
Calendar of Events
Adrenal Health Article
Natural Allergy Relief
Breath work and Massage
A Light at the End of the Carpel Tunnel
Central Nervous System
Chi Nei Tsang
Clare Zhang Curriculum Vitae
Chinese Pediatric Massage
Diabetes and Massage
Emotional Health, Stress, and the Nervous System
Everything is Energy: What is energy healing?
Lomi Lomi, Ke Ala Hoku
Lupus and Massage
Is Life Chaotic? Maintaining Your Center in the Storms
Lymphatic Massage benefits
Massage through the Eyes and Hearts of the Therapists at Peaceful Spirit Massage & Wellness Centers
Menopause- alternative treatments
Migraines: Causes, Prevention, and Treatment
My Personal Struggle with back pain
My Journey to Providing Medical Massage By: Rick, LMT Peaceful Spirit Massage & Wellness Centers
Spring Time In Chinese Medicine Five Element Theory
Should Massage Hurt?
Stress and Heartmath
Sweet SUMMER & Abundant MONSOONS
Synergistic results using multiple modalities
True Arrival of Spring
Winter: Resting or Feasting?
Women's Health through Traditional Chinese Medicine
The Paradigm of Holistic Health and Five Element Acupuncture
Massage Contraindication Article
What to Expect During Your First Massage
The Benefits of AromaTouch
Larry Stroke Recovery Letter and Video
Notice of Privacy Practices
Healing Through the Holidays
Qi Gong and Tai Chi Classes
Recipe of the Month
Corporate On-site Chair Massage Programs
The Warrior Workout With Donna
1. Peaceful Spirit Massage & Wellness Centers health History Form
2. Legal Home Address
3. CELL phone
4. How did you hear about Peaceful Spirit? Help us thank our referrers!
Peaceful Spirit Web Site
Search Engine like Google, Yahoo or Bing
Social Media like Face Book, Twitter or Linked In
5. If you checked referral, whom may we thank? If other, please explain
6. Date of Birth: Please include month, day and year, thank you
7. Please rate you stress level:
1 Very low
5 Very High
8. Hobbies or favorite exercise or sports
9. What type of work do you do?
10. Employer Name
11. Employer phone number
12. Please list all repetitive movements you do (*required):
13. What is your primary reason for your visit today? (*required):
14. Which professional treatments have you received? Check all that apply
15. Which type do you receive most frequently? (*required)
16. How frequently? (*required)
17. When was your last session?
18. What do you receive treatments for? (*required)
19. If you could change anything with your health, what would you change?
20. What will you be able to do again once those changes happen?
21. What "other" changes would you like to see? Not health related.
22. Are you currently receiving medical care? (*required)
23. If yes, for what condition are you under care?
24. Current symptoms? Check all that apply
Impaired balance or vertigo
Visual, Audio or sensory disturbance or impairment
Ringing or buzzing in the ears
Loss of concentration
25. Health History, check all that apply
Diabetes 1 or 2
26. Health History, check all that apply
High Blood Pressue
Sexually transmitted disease
Drug or alcohol addiction
27. List: Surgeries, Head Injuries, Broken Bones, Serious Falls or N/A
28. Please list all allergies, or N/A
29. Please list all medications, vitamins & supplements or N/A
30. If you have pain or have been in an accident, please complete:
31. Rate your pain level
1 Very low
32. Type of pain? Check all that apply
33. Is the pain constant or does it come and go?
34. When did your symptoms begin?
35. How frequent are the symptoms?
36. Does the problem interfere with:
Daily Living Activities
37. Which movements create the pain?
38. If your condition is related to an accident complete:
39. Type of accident?
40. Accident report filed with:
41. Attorney's name if applicable
42. Referring physician, if applicable
43. Date of last full physical?
44. Date of last X-ray
45. Date of last Blood tests
46. Date of last MRI/CT/Bone scan
47. Date of last urine test
48. 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.
I have read and accept these terms and conditions.
49. Client or patient Signature
50. Parent or guardian signature for children/dependents or enter N/A
51. 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.
Please feel free to discuss any questions or concerns with the Doctor before signing
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
Myotherapy-soft tissue therapies
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.
53. Parent or guardian signature for children/dependents or enter N/A
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