Associated Bodywork & Massage Professionals
MEMBER
Practitioner/Clinic Name: Screening Questionnaire
Contact Information
(page 1 of 2)
Clien
t Information
Client Name: Date:
Preferred phone number: Best time to call:
Email address: 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:
