Massage Therapy Intake

Patient Information

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Please enter your information as it should appear on your medical record.

Full Name Today's Date Street Address City / State ZIP Code Cell Number Email Referred By Date of Birth Allergies Sports & Activities Current Medications

Medical History

Primary Care Physician

Are you under medical care for any of the following? heart conditions varicose veins neck injury osteoporosis cancer diabetes Crohn's disease nervous disorders high/low blood pressure phlebitis/circulatory problems back injury rheumatoid arthritis kidney disease asthma/respiratory pelvic inflammatory disease Whiplash fainting or dizziness headaches or migraine jaw or ear pain osteoarthritis skin conditions fibromyalgia epilepsy

Other Medical Conditions

Treatment History

Have you received care from any of the following? Physiotherapist Chiropractor Massage Therapist Naturopath Other

Other Provider Reason for Treatment Number / Duration of Treatments

Have you had surgery in the past? Yes No

If yes, what / where?

Have you had fractures or sprains in the past? Yes No

If yes, what / where?

Have you had serious illnesses in the past? Yes No

If yes, what / where?

Have you had any of the following regarding your current condition? Physician's examination x-ray other diagnostic tests

What relieves your pain? What aggravates your pain?

Health History Signature

I confirm that I have reviewed the health history information provided above.

Patient / Guardian Signature

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Typed Legal Name — Signature Alternative

I understand that the massage therapist is providing massage therapy services within their scope of practice as defined by the California Massage Therapy Association.

I hereby consent for my therapist to treat me with massage therapy for the above noted purposes. I understand that such treatment is guided by a chiropractor and any questions I have about my massage will be discussed by my massage therapist with a chiropractor.

I acknowledge that the therapist is not a physician and does not diagnose illness or disease or any other physical or mental disorder. I clearly understand that massage therapy is not a substitute for a medical examination. I acknowledge that no assurance or guarantee has been provided to me as to the results of the treatment. I acknowledge that with any treatment there can be risks and those risks have been explained to me and I assume those risks.

I acknowledge and understand that the therapist must be fully aware of my existing medical conditions. I have completed my medical history form as provided by my chiropractor and disclosed to the therapist all of those medical conditions affecting me. It is my responsibility to keep the chiropractor and the massage therapist updated on my medical history. The information I have provided is true and complete to the best of my knowledge.

I have read the above noted consent and I have had the opportunity to question the contents and my therapy. By signing this form, I confirm my consent to treatment and intend this consent to cover the treatment discussed with me to deal with my physical condition and for which I have sought treatment. I understand that at any time I may withdraw my consent and treatment will be stopped.

I acknowledge that Chiropractic Neurology Center located at 1225 E Wardlow Rd, Long Beach, CA 90807, has offered/presented me with a copy of their privacy practices. This notice explains how my protected health information (PHI) may be used and what Chiropractic Neurology Center's responsibilities are regarding my privacy rights. I have been provided a copy of the privacy practices.

I have read and understand the informed consent above and agree to massage therapy treatment. Patient / Guardian Name

Patient / Guardian Signature

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Typed Legal Name — Signature Alternative

Date Signed

Witness: Reserved for Chiropractic Neurology Center staff.

Emergency Contacts

If you have an emergency, whom may we contact? Please provide the name, address, phone number, and relationship for each individual.

Emergency Contact 1

Full Name Phone Number Address Relationship

Emergency Contact 2

Full Name Phone Number Address Relationship

Communication Authorization

Authorization to Verbally Communicate With a Family Member or Friend

Do you authorize CNC to verbally communicate your health information with designated family members or friends? Yes, I authorize verbal communication. No, I do not authorize verbal communication.

FINAL STEP

Review Your Information

Please review your answers before completing this form.

Ready to Submit

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Chiropractic Neurology Center