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Trinity Alignment Therapeutics LLC PATIENT INTAKE FORM

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PATIENT INTAKE FORM Name:__________________________________________________ Address:_______________________________________City:___________________Zip Code: ___________ E-Mail:___________________________________________________________________________________ Phone (Cell): _______________________ (Home): _______________________ Birth Date: _________________________ Age:_____ Occupation:____________________________________ Is this appointment after an auto accident or injury of some kind? Yes _____ No______ If yes, Please give date of accident(s) and explain what happened or occurred: _____________________________________________________________________________________________ _____________________________________________________________________________________ Describe the main reason for your visit today,what are your health concerns or priority?: _____________________________________________________________________________________________ ____________________________________________________________________________________- Are there any area’s that you do not want to receive massage or any area’s you would like specifically focused on? (ie, feet, stomach, etc.) _____________________________________________________________________________________________ _____________________________________________________________________________________ Please describe any current or chronic pain, injuries or trauma to your body/mind or any other relevant diagnosis from medical practitioner (ie, whiplash – dec 2009, chronic fatigue diagnosis – april 2012, or Chronic Depression/Anxiety. Any Emotional Trauma’s) _____________________________________________________________________________________________ _____________________________________________________________________________________ Do you exercise regularly? Yes_____ No_____ If yes, describe what kind and how often: _________________________________________________________________________________________ Are youpregnant ornursing? ____Yes _____No If yes, Howmany weeks? ________ Which level oftreatment wouldyou like to pursue?(circle the letter) A. I would like the minimal amount of care to“patch up symptoms” dealingwith myconcerns. B. I would like to resolve mysymptoms and“fixthe cause” of myconcernedareas. C. I would like to overcomemy current issues andmove onto“optimal healthandwellness.”
Medical History (Circle all that apply to you): Musculoskeletal Nervous Digestive Lymph/Immune Fibromyalgia Depression GERD (reflux) Edema Rheumatoidarthritis Multiple sclerosis Ulcers Leukemia/Lymphoma Osteoarthritis Post polioSyndrome Crohn’s disease HIV/AIDS TMJ dysfunction Headaches Ulcerativecolitis Chronic fatigue syndrome Strains/Sprains/Tendinitis Stroke Irritable bowel Lupus Carpal tunnel syndrome Seizure disorders Gallstones Other Autoimmune- Thoracic outlet syndrome Reduced sensation Cirrhosis Disorders: Adhesive Capsulitis Sleep disorders Hepatitis Whiplash Chemical dependency Reproductive Circulatory Skin Respiratory Breast Cancer Anemia Boils Asthma Endometriosis Thrombophlebitis Fungal infections Emphysema Ovarian Cysts Deep Vein Herpes simplex Sinusitis ProstateCancer Thrombosis Warts Chronic Cough PMS High BloodPressure Eczema Difficulty breathing Menopause Heart disease Psoriasis Hysterectomy Varicose veins Skin cancer Clottingdisorders FoodAllergies Endocrine Urinary Other: (please listall surgeries and dates) Diabetes Kidney Stones Hypo-thyroidism Renal failure Hyper-Thyroidism UTI’s PLEASESPECIFY AREAS OFGENERAL OR CHRONIC PAIN BY CIRCLING/MARKING BELOW:
TrustedFriendor Family Memberin case of Emergency: ________________________________Phone: _____________________ Howdid youhear about TrinityAlignment Therapeutics LLC? _______________________________________________________ PLEASEREAD THE FOLLOWINGSTATEMENTS, THEN SIGN ATTHE BOTTOMOFTHEPAGE: Privacy Policy: We want youto knowhowyour Patient Health Information(PHI)will be used andyour rights concerningyour records. Please readthe followingcarefully. Your PHI will be used for the sole purpose of treatment,payment,healthcare operations andcoordinationof your care.Youhave the right to examine andobtain a copyof your own records at any time. Youmayrequest restrictions ofuse of your records at anytime but must do so in writing. This request will only affect subsequent activityfrom thetime of your request. Signingthis formcertifies your understanding, agreement andconsent ofuse of your PHI.Your writtenconsent is requiredonly once for all subsequent care giventoyouby us. Youmay revoke this consent at anytime in writing. This will not affect the use of those records for care givenprior to thewrittenrequest to revokeconsent but would apply to any care given after that request has been received. Or Commitment: Youare important to us. If at theend of your session youare not satisfiedwith the service youhavereceivedpleaselet us know. It is the Client’s (your) responsibility to explain anddiscuss all physical conditions (acute orchronic)with the Therapist so that they may accurately devise thecorrect treatment modalityforyoubefore youbegin a session. The Massage/Energy worktreatment given is for thesole purpose of stress reduction,relief frommuscle tensionof spasmandtoincrease circulationandenergy flow. It is not a substitute formedical treatment by your physician. ____ (Initial) Rules Of Conduct: Inappropriate behaviorfrom clients or therapists will not be toleratedin any manner. If any sexual flirtation occurs, a police report will be made, a notification to D.O.R.Aandproper legal actionwill be taken. A Sexual Abuse Fine of $1,000.00will be assessed andpursued. We have theright torefuse ordiscontinue service at any timeforanyreason. Youagree tofollowall proper rules, policies andregulations indicatedeitherverballyorwrittenby theTherapist. Violations will be taken seriously. _____(Initial) Payment Policy: Payment is dues in full at the time ofservice. Payment maybe made by cash, check,credit card, or health savings account. Session lengthandcomponents vary. Your session will be customizedtoyour needs. Please discuss any time, financial orother concerns before your session begins. If youare unable tokeep an appointment,youunderstandthat a 24 hour notice is required, otherwise you will be chargeda fee of $35 forfirst occurrence and$55thereafter for the timereserved. I have read and I fullyunderstand this form in its entirety. If at any timethere are changes in the information given or in my health condition, I willnotifymy therapist, and updatethis form before receiving additionalmassage/energy treatments. I have read and understand how myPHI willbeused and I agree to these policiesand procedures. _____________________________________ ____________________________________ CLIENT SIGNATURE/ DATE THERAPISTSIGNATURE/ DATE THERAPISTNOTES (Practitioner Use Only):

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Trinity Alignment Therapeutics LLC PATIENT INTAKE FORM

  • 1. PATIENT INTAKE FORM Name:__________________________________________________ Address:_______________________________________City:___________________Zip Code: ___________ E-Mail:___________________________________________________________________________________ Phone (Cell): _______________________ (Home): _______________________ Birth Date: _________________________ Age:_____ Occupation:____________________________________ Is this appointment after an auto accident or injury of some kind? Yes _____ No______ If yes, Please give date of accident(s) and explain what happened or occurred: _____________________________________________________________________________________________ _____________________________________________________________________________________ Describe the main reason for your visit today,what are your health concerns or priority?: _____________________________________________________________________________________________ ____________________________________________________________________________________- Are there any area’s that you do not want to receive massage or any area’s you would like specifically focused on? (ie, feet, stomach, etc.) _____________________________________________________________________________________________ _____________________________________________________________________________________ Please describe any current or chronic pain, injuries or trauma to your body/mind or any other relevant diagnosis from medical practitioner (ie, whiplash – dec 2009, chronic fatigue diagnosis – april 2012, or Chronic Depression/Anxiety. Any Emotional Trauma’s) _____________________________________________________________________________________________ _____________________________________________________________________________________ Do you exercise regularly? Yes_____ No_____ If yes, describe what kind and how often: _________________________________________________________________________________________ Are youpregnant ornursing? ____Yes _____No If yes, Howmany weeks? ________ Which level oftreatment wouldyou like to pursue?(circle the letter) A. I would like the minimal amount of care to“patch up symptoms” dealingwith myconcerns. B. I would like to resolve mysymptoms and“fixthe cause” of myconcernedareas. C. I would like to overcomemy current issues andmove onto“optimal healthandwellness.”
  • 2. Medical History (Circle all that apply to you): Musculoskeletal Nervous Digestive Lymph/Immune Fibromyalgia Depression GERD (reflux) Edema Rheumatoidarthritis Multiple sclerosis Ulcers Leukemia/Lymphoma Osteoarthritis Post polioSyndrome Crohn’s disease HIV/AIDS TMJ dysfunction Headaches Ulcerativecolitis Chronic fatigue syndrome Strains/Sprains/Tendinitis Stroke Irritable bowel Lupus Carpal tunnel syndrome Seizure disorders Gallstones Other Autoimmune- Thoracic outlet syndrome Reduced sensation Cirrhosis Disorders: Adhesive Capsulitis Sleep disorders Hepatitis Whiplash Chemical dependency Reproductive Circulatory Skin Respiratory Breast Cancer Anemia Boils Asthma Endometriosis Thrombophlebitis Fungal infections Emphysema Ovarian Cysts Deep Vein Herpes simplex Sinusitis ProstateCancer Thrombosis Warts Chronic Cough PMS High BloodPressure Eczema Difficulty breathing Menopause Heart disease Psoriasis Hysterectomy Varicose veins Skin cancer Clottingdisorders FoodAllergies Endocrine Urinary Other: (please listall surgeries and dates) Diabetes Kidney Stones Hypo-thyroidism Renal failure Hyper-Thyroidism UTI’s PLEASESPECIFY AREAS OFGENERAL OR CHRONIC PAIN BY CIRCLING/MARKING BELOW:
  • 3. TrustedFriendor Family Memberin case of Emergency: ________________________________Phone: _____________________ Howdid youhear about TrinityAlignment Therapeutics LLC? _______________________________________________________ PLEASEREAD THE FOLLOWINGSTATEMENTS, THEN SIGN ATTHE BOTTOMOFTHEPAGE: Privacy Policy: We want youto knowhowyour Patient Health Information(PHI)will be used andyour rights concerningyour records. Please readthe followingcarefully. Your PHI will be used for the sole purpose of treatment,payment,healthcare operations andcoordinationof your care.Youhave the right to examine andobtain a copyof your own records at any time. Youmayrequest restrictions ofuse of your records at anytime but must do so in writing. This request will only affect subsequent activityfrom thetime of your request. Signingthis formcertifies your understanding, agreement andconsent ofuse of your PHI.Your writtenconsent is requiredonly once for all subsequent care giventoyouby us. Youmay revoke this consent at anytime in writing. This will not affect the use of those records for care givenprior to thewrittenrequest to revokeconsent but would apply to any care given after that request has been received. Or Commitment: Youare important to us. If at theend of your session youare not satisfiedwith the service youhavereceivedpleaselet us know. It is the Client’s (your) responsibility to explain anddiscuss all physical conditions (acute orchronic)with the Therapist so that they may accurately devise thecorrect treatment modalityforyoubefore youbegin a session. The Massage/Energy worktreatment given is for thesole purpose of stress reduction,relief frommuscle tensionof spasmandtoincrease circulationandenergy flow. It is not a substitute formedical treatment by your physician. ____ (Initial) Rules Of Conduct: Inappropriate behaviorfrom clients or therapists will not be toleratedin any manner. If any sexual flirtation occurs, a police report will be made, a notification to D.O.R.Aandproper legal actionwill be taken. A Sexual Abuse Fine of $1,000.00will be assessed andpursued. We have theright torefuse ordiscontinue service at any timeforanyreason. Youagree tofollowall proper rules, policies andregulations indicatedeitherverballyorwrittenby theTherapist. Violations will be taken seriously. _____(Initial) Payment Policy: Payment is dues in full at the time ofservice. Payment maybe made by cash, check,credit card, or health savings account. Session lengthandcomponents vary. Your session will be customizedtoyour needs. Please discuss any time, financial orother concerns before your session begins. If youare unable tokeep an appointment,youunderstandthat a 24 hour notice is required, otherwise you will be chargeda fee of $35 forfirst occurrence and$55thereafter for the timereserved. I have read and I fullyunderstand this form in its entirety. If at any timethere are changes in the information given or in my health condition, I willnotifymy therapist, and updatethis form before receiving additionalmassage/energy treatments. I have read and understand how myPHI willbeused and I agree to these policiesand procedures. _____________________________________ ____________________________________ CLIENT SIGNATURE/ DATE THERAPISTSIGNATURE/ DATE THERAPISTNOTES (Practitioner Use Only):