Marjorie Dickinson VanPelt, LMT
1223 King Street
Jacksonville, Florida 32204
904.945.4540 w www.Marjorielmt.com
MM34313,MA41381
Client INFORMATION
Name:______Date:______
Address:______
City: ______State:______Zip:______
Home Ph: ______Work Ph: ______Cell:______
Date of Birth:______Age:______
Occupation:______
E-mail: ______
Sex : Male Female Status: Minor Single Married Divorced widowed
Whom should we thank for referring
you?:______
Past Experience with reflexology/manualtherapy:______
CASE HISTORY
To aid in your evaluation, please be as accurate and as descriptive as possible
Reason for consultation (if no complaint, continue to past history):______
______
Describe chief complaint:______
______
Complaint began when and how?:______
How frequent is complaint present how long does it last?______
What makes the complaint worse:______
What makes the complaint better:______
Does the complaint move to other areas? Where?______
Rate the intensity of complaint: (no pain) 012 3 5 6 7 8 910 (worst possible)
How limited are you in activities; (not at all) 012 3 4 5 6 7 8 9 10 (totally)
Additional information about complaint (previous treatment, etc):______
______
PAST HISTORY
List any past accidents, injuries, and/or surgeries:______
List any current Drugs / Medications you are using: (include reason):______
Any Testing procedures in the last year (blood work, x-rays, etc.) ______
Family History (cancers, strokes, high blood pressure, diabetes, etc…):
______
Current exercise program:______
Describe your work environment:______
What do you do in your spare time (hobbies):______
What is your perceived health potential: ( poor )1 2 3 4 5 6 7 8 9 10 ( great )
What types of Therapeutic bodywork are you interested in? ( please circle ):
Symptom Relief Care Corrective Care Wellness Care
short term symptom Restoring function to Optimizing your health
focused minimize reoccurrences potential
Please circle if you are interested in any of the following:
Care plan packages Corrective Exercises/Stretches hydrotherapy
aromatherapy
Additional comments or concerns;______
______
I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize Marjorie Dickinson VanPelt, LMT to provide me with Therapeutic Bodywork, in accordance with the state of Florida's statutes.
Client or Parent Signature: ______
Date:______
Use the letters below to indicate the type and location of your sensations right now.
A=ache B=burning N=numbness P=pins & needles
S=Stabbing E=electric O= other______
pain right now (no pain) 0 1 2 3 4 5 6 7 8 9 10 (unbearable)
Marjorie Dickinson VanPelt, LMT
1223 King Street
Jacksonville, Florida 32204
904.945.4540 w www.marjorielmt.com
MM34313,MA41381
Financial Policy
please read The financial POLICY below and initial.
payment at the time of service
______patient agrees to pay in full at the time of office visit for services rendered.Cash, check, Visa, MasterCard, American Express, and Discover are all accepted.
For insurance holders.: this office does not currently submit insurance claims for services rendered. The Patient will be responsible for filing his/her claims. Reimbursements will be made directly to the patient for services covered based on his/her insurance policy and if all co-payments and deductibles have been met. In some instances, the clinic may be paid directly. If this occurs we will directly contact the patient for arrangements.
.
24 hour cancellation policy
Our policy states: the patient is required to give their scheduled therapist no less than 24 hours notice for an appointment cancellation. Each client will be given one grace first offense.
______I have read and understand the above Cancellation Policy.
My signature below verifies that I have read and fully understand the above information, which pertains to my particular situation. I understand and accept that I am ultimately responsible for all charges incurred for services rendered at Marjorie Dickinson VanPelt, LMT.
Patient Signature:______Date:______
Marjorie is available to answer any questions or concerns (904) 945-4540.
ACKNOWLEDGMENT OF RECEIPT
OF
NOTICE OF PRIVACY PRACTICES
I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read them or declined the opportunity to read them and understand the Notice of Privacy Practices. I understand that this form will be placed in my patient chart and maintained for six years.
______
Patient Name (please print) Date
______
Parent, Guardian or Patient’s legal representative
______
Signature
THIS FORM WILL BE PLACED IN THE PATIENT’S CHART AND MAINTAINED FOR SIX YEARS.