Medical Massage

(click here to download Microsoft Word version of this form to fill out then e-mail)

Initial Patient Questionnaire

At present, 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_______________________________________




Phone #____________________________________________


Prescription Diagnoses (DX) Number(s) ________________________________

(if no Diagnoses Numbers are listed on Prescription,

contact Referring Physician to obtain)