Initial Patient Questionnaire

Medical Massages are available on a house-call basis only.

Massage Therapist:: Howard Northrup, LMT  MA# 35627

 

Prior to your first appointment, I will need the following information.

Please print page, enter all information, and submit to me, Howard Northrup, LMT.

 

Patient Name ____________________________ SS#_____-____-______

 

Date of Injury/Illness__________________________________________

 

Type of Insurance:  __Auto   __Work comp   __Maj. Med/Indemnity

 

If work comp, Employer Name at time of injury_____________________

_______________________________________ phone________________

 

Name of Insured________________________ SS#_____-____-______

 

Insurance Company___________________________________________

 

Claim Representative__________________________________________

 

Claim Rep - Phone_______________________________________

 

Group or Policy #_____________________________________________

 

Claim or Case #_______________________________________________

 

Referring Physician Name_______________________________________

 

Address____________________________________________

 

Phone #____________________________________________

 

Prescription Diagnoses (DX) Number(s) ________________________________

(if no Diagnoses Numbers are listed on Prescription,

contact Referring Physician to obtain)