Practitioner/Clinic Name: Screening Questionnaire Contact ...
Practitioner/Clinic Name: Contact Information
Screening Questionnaire
(page 1 of 2)
Client Information Client Name: Preferred phone number: Email address:
Date: Best time to call: Preferred form of communication:
Massage Information How did you hear about me? (referral, Facebook, etc.) Is this a gift certificate? Yes No Massage history:
Have you had a massage/bodywork before? Yes No Frequency: Types of massage/bodywork received: Preferred types of massage:
Reasons for seeking massage? (relaxation, injury, etc.)
Description of injury/health condition:
Possible complications/medications:
Expected outcomes (functional improvement, symptom relief, wellness):
Typical activities of daily living (affected by condition?):
Occupation (affected by condition?):
Are you seeking insurance reimbursement? Yes No Car collision/personal injury? On-the-job injury? Private health insurance? Do you have a physician referral with diagnosis codes?
Let clients know if you provide billing services, and if so, for what types of claims, or if you will simply provide receipts and/or copies of records for them to submit for reimbursement. Let clients know a physician referral demonstrating medical necessity is required for insurance reimbursement/health savings account reimbursement regardless of who submits bills.
Best times for massage:
MEMBER
Associated Bodywork & Massage Professionals
Practitioner/Clinic Name: Contact Information
Communication Checklist Fees/forms of payment Cancellation/No-show policy Late arrival policy Confidentiality Parking/directions Work setting Clothing/shiatsu Modesty/Nonsexual/draping Food/drugs/alcohol Oils/lotions/allergies
Do you have special needs I should prepare for:
Do you have any questions or concerns:
If out-call, ask for directions, parking, or special instructions:
Packet Checklist Health Information Health Status Report Billing Information Directions/map
Date sent
Additional Notes
Screening Questionnaire
(page 2 of 2)
MEMBER
Associated Bodywork & Massage Professionals
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