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Health Information Anne-Marie Pronk-Ozaki LMT, MMT, CES, MA

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Associated Bodywork & Massage Professionals
MEMBER
Health Information
Anne-Marie Pronk-Ozaki LMT, MMT, CES, MA
832-628-2255 The Woodlands, TX
massagetherapybyannemarie.massagetherapy.com
npi# 180 13 23 787
(page 1 of 2)
Client Contact Information
Client Name: ___________________________________ Date: ____________
Date of Birth: ____________ Gender: ____________
Address: _________________________________________________________________________________
Phone: _______________________________________ Email: ___________________________________
Referred by: ___________________________________
Emergency contact: _____________________________ Phone: ___________________________________
Physician/Health-care Provider name: __________________________ Phone: ____________________
Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)? Yes ☐ No ☐
Do you have a physician referral/prescription? Yes ☐ No ☐
Are you seeking insurance reimbursement? Yes ☐ No ☐ If yes, please complete the Billing Information form.
Type of insurance coverage for this claim: Car Collision Worker’s Compensation Private Health
Massage Information
Have you ever received professional massage/bodywork before? Yes ☐ No ☐
How recently? ___________________________________
What types of massage/bodywork do you prefer? ___________________________________
What kind of pressure do you prefer? Light Medium Firm
What are your goals/expected outcomes for receiving massage/bodywork?
_________________________________________________________________________________________
_________________________________________________________________________________________
How
do you feel today? ______________________________________________________________________
List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
______________________________________________________________________________________________
______________________________________________________________________________________________
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)? Yes No
Explain:
______________________________________________________________________________________________
______________________________________________________________________________________________
List the medications you currently take:
______________________________________________________________________________________________
______________________________________________________________________________________________
Are you wearing contacts? Yes ☐ No ☐
Are you wearing dentures? Yes ☐ No ☐
Are you wearing a hairpiece? Yes ☐ No ☐
Are you pregnant? Yes ☐ No ☐
Associated Bodywork & Massage Professionals
MEMBER
Health History
Have you had any injuries or surgeries in the past that may influence today’s treatment?
_____________________________________________________________________________________________
Check any of the following health conditions that you currently have (If you are unsure, please ask):
blood clots infections congestive heart failure contagious diseases pitted edema
Please answer honestly, as massage may not be indicated for the above conditions.
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received:
Current Past Muscle or joint pain _____________________________________
Current Past Muscle or joint stiffness _____________________________________
Current Past Numbness or tingling _____________________________________
Current Past Swelling _____________________________________
Current Past Bruise easily _____________________________________
Current Past Sensitive to touch/pressure _____________________________________
Current Past High/Low blood pressure _____________________________________
Current Past Stroke, heart attack _____________________________________
Current Past Varicose veins _____________________________________
Current Past Shortness of breath, asthma _____________________________________
Current Past Cancer _____________________________________
Current Past Neurological (e.g. MS, Parkinson’s, chronic pain) _____________________________________
Current Past Epilepsy, seizures _____________________________________
Current Past Headaches, Migraines _____________________________________
Current Past Dizziness, ringing in the ears _____________________________________
Current Past Digestive conditions (e.g. Crohn’s, IBS) _____________________________________
Current Past Gas, bloating, constipation _____________________________________
Current Past Kidney disease, infection _____________________________________
Current Past Arthritis (rheumatoid, osteoarthritis) _____________________________________
Current Past Osteoporosis, degenerative spine/disk _____________________________________
Current Past Scoliosis _____________________________________
Current Past Broken bones _____________________________________
Current Past Allergies _____________________________________
Current Past Diabetes _____________________________________
Current Past Endocrine/thyroid conditions _____________________________________
Current Past Depression, anxiety _____________________________________
Current Past Memory Loss, confusion, easily overwhelmed _____________________________________
Comments:
______________________________________________________________________________________________
______________________________________________________________________________________________
Consent for Treatment
If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my
level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and
that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that
massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and
that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain
medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated
as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that
any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the
scheduled appointment. Understanding all of this, I give my consent to receive care.
Client Signature: _____________________________________________________________ Date: ____________
Parent or Guardian Signature (in case of a minor): ___________________________________ Date: ____________
Anne-Marie Pronk-Ozaki LMT, MMT, CES, MA
832-628-2255 The Woodlands, TX
massagetherapybyannemarie.massagetherapy.com
npi# 180 13 23 787
Health Information
(page 2 of 2)
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Health Information Anne-Marie Pronk-Ozaki LMT, MMT, CES, MA

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Completed 7 July 2021

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