Intake forms, practical?

[Genesis]

Moderatorial comment: This thread was split from "Illegal to Photocopy Intake Forms?" as it is a client based discussion.

I AM a client and I am very glad to see HIPAA being applied here. I have gone to therapists before who've had me fill out a "medical information and contact" form and I SERIOUSLY resent being asked for that type of information by someone who does NOT have a medical degree. (Quickly now as this is in the 5 minutes prior to my appointment, if I put down on the form that I take 60mg of fexofenadine twice a day, what are you going to do differently in my session? And there IS something you SHOULD do...but hopefully, you get my point.) I feel that it is perfectly legitimate for you to have contact info and a list of contraindications for massage on the form and any disclaimers you may wish.

Now, to be on the other side (a little bit)...as a client, I would like my contact info to be available to both the surviving business and any therapist I saw on a regular basis (say, at least 5 times)...if I didn't see a therapist more than twice, that was no accident on my part and I really don't want him/her trying to solicit my business.

 

[Ian Loves Noel <3]

irish-george:

I know health intake forms can sometimes feel invasive, but it IS important for your bodywork therapist to be informed about your current health and any meds you are taking. Many conditions and medications contraindicate certain forms of massage. If you are seeing a practitioner who is not asking you about your health, you may want to look elsewhere.

Perhaps I am misunderstanding your post.

 

[death]

I AM a client and I am very glad to see HIPAA being applied here. I have gone to therapists before who've had me fill out a "medical information and contact" form and I SERIOUSLY resent being asked for that type of information by someone who does NOT have a medical degree. (Quickly now as this is in the 5 minutes prior to my appointment, if I put down on the form that I take 60mg of fexofenadine twice a day, what are you going to do differently in my session? And there IS something you SHOULD do...but hopefully, you get my point.) I feel that it is perfectly legitimate for you to have contact info and a list of contraindications for massage on the form and any disclaimers you may wish.

Now, to be on the other side (a little bit)...as a client, I would like my contact info to be available to both the surviving business and any therapist I saw on a regular basis (say, at least 5 times)...if I didn't see a therapist more than twice, that was no accident on my part and I really don't want him/her trying to solicit my business.

I understand your sentiment, but we ask that information because it is required by law! If you are taking a medication that I do not recognize, I will ask what condition it is treating, and what limitations come with it. Because I work with the elderly, I know the blood thinners on sight, and know that they will bruise more easily, for instance.

I try to have my new clients fill out the intake form and return it to me prior to the first appointment, so that I can look up any medications they are taking, so that I will know if there is anything different that I need to do/be aware of. We had a PDR in the clinic office at school, and were taught to look up all medications listed every time. I hope this will make you more comfortable about sharing this information. It really is for your own protection. If a therapist doesn't seem to be reading the intake form, please feel FREE to point out your medication and tell him/her what that means for your session. Do what is in your own best interest - it is right.

HIPAA regulations are always followed in my business. In my area (I cannot speak for all and I am not trying to), private MT's, those who work for chiropractors and those who are in clinic type settings are very careful to apply the HIPAA regulations and to follow safety standards. Spas and hair salons (in my area, so please do not be offended if you are a spa or salon owner or MT!!) have no clue that there ARE any regulations, and MT's either are very frustrated until they finally quit, or they just don't care, either. I will NOT go to a spa for a massage, and in a salon, I need to know the MT well enough to ask beforehand.

 

[Pompal 09.]

there is no law in florida that requires an intake form... unless of course, you're doing medical and want insurance reimbursement.


there have been many times and in different settings i have received services without an intake form. i think this is a local or state thing.

as for hippa, i don't offer medical massage, but i have to comply. noone gets any info unless there is consent from the client. (but i'm an independent)

 

[Pandora T.]

I guess I did know that the laws vary from state to state - that is a good point, Mush. I should say in WI, we are required to have medical intake forms, even for relaxation only massage. There are contraindications and cautions even for Swedish only, and we are responsible for that. Some of it I think is really silly, more superstition than science, though!

 

[Down]

I SERIOUSLY resent being asked for that type of information by someone who does NOT have a medical degree. ..........f I put down on the form that I take 60mg of fexofenadine twice a day, what are you going to do differently in my session? And there IS something you SHOULD do...but hopefully, you get my point.) .

If I hadn't known what it was, or had my PDR I would ask you what it was for.
I would explain to you that a massage COULD exacerbate the effects of the allergy meds(drowsiness). I may have you sit a bit after the massage to make sure you were ok to drive.
I do have the medical experience behind me but most do not. PDR, s MT pharma texts are all valuable resources.

Robyn

 

[Pompal 09.]

more info...

I guess I better respond here before I just come across as cranky!
First, the state I am in doesn't require a massage therapist to collect any health info prior or after service...I personally believe that it is only used for screening purposes (no one has ever requested the info in advance of the appointment nor has anyone taken over 30 seconds or so to look over it and I take several medications and have had several surgeries).

(About the fexofenadine reference...that is an antihistimine and if you are collecting that info, I'd expect you to know that and ask if I am allergic to any scents or oils that I may come into contact with during the massage...in my situation, you could trigger an asthma attack with a scent or powder.)

Now, the most invasive of forms ask things like surgeries and medications but very few ask about injuries and none that I've ever seen ask about degenerative conditions. (I had a boss with a rare kind of bone cancer that caused one of his vertabrae to collapse...you wouldn't want him on your massage table.)

Anyway, back to my main point: All of the forms I've seen disclaim any medical benefit from a massage (though I feel that there are some), and point out that the CMT doesn't have a "medical" background. From this, the therapist doesn't have the background to evaluate the information being requested, so why invade someone's privacy in the first place? Just make the form consist of contact information, a list of known contraindications, maybe a disclaimer that the client should get an OK from his physician (if you're in a lawsuit-happy state) if there is any doubt about the safefy of massage for that particular client, and any other disclaimers that make you and your attorney feel better. Too many entities are requesting far more info than is necessary and that isn't a good thing. The info can be used in all sorts of undesirable ways...I know, I had my identity stolen twice in the last two years and all from info mined by information bureaus (not given by me) who, then, had their computer security breached.

 

[balloon molly]

more info...

Just make the form consist of contact information, a list of known contraindications, maybe a disclaimer that the client should get an OK from his physician (if you're in a lawsuit-happy state) if there is any doubt about the safefy of massage for that particular client, and any other disclaimers that make you and your attorney feel better.

What you are saying would lead me to believe that the therapists you have seen in the past are using a poorly written intake forms. As to having one listing all known contraindications, well that would take up an entire form on it's own.

Ours requests basic info like name, address, phone number ect. Then we have a section that asks about pertinent medical conditions such as cancer, diabetes and allergies. We do ask about medications as this is info that we need in order to provide the best and safest treatment for you. Most therapists do have a PDR or some other reference book that they use to look up any medications that they are unfamiliar with.

We then have a section that asks about surgeries, accidents and injuries. Yes, we do need to know about surguries. We have to take into account such things as scar tissue when evaluating your areas of pain. For instance abdominal scar tissue can have an effect on the low back. If you've had recent surgery then massage may be contraindicated or we may have to modify the treatment. We then have a section for the client to indicate their current areas of pain and concern. Then of course the legal disclaimer at the bottom. Can't do anything without the ole CYA can we?

No, we're not doctors or pharmacists but in some states (as here in Florida) we are considered health care providers and are regulated by the same governing board as doctors, nurses, PTs ect..... We are held to the same regulations such as confidentiality and professionalism. We can be sued for malpractice or negligence.

The medical history forms are not just so we can be nosy or sell your information. If fact, we'd be in big trouble if we did something like that. The intake forms are needed so we can provide you with the best care.

I know that they're a PIA but we don't do it for our enjoyment. We do it to protect our clients.

Angie

 

[bigestpimpin]

more info...

I guess I better respond here before I just come across as cranky!

First, the state I am in doesn't require a massage therapist to collect any health info prior or after service...I personally believe that it is only used for screening purposes (no one has ever requested the info in advance of the appointment nor has anyone taken over 30 seconds or so to look over it and I take several medications and have had several surgeries).

(About the fexofenadine reference...that is an antihistimine and if you are collecting that info, I'd expect you to know that and ask if I am allergic to any scents or oils that I may come into contact with during the massage...in my situation, you could trigger an asthma attack with a scent or powder.) My intake form asks if there are allergies, and I DO read the intake form after my client has filled it out. If there is no response to that question on the intake form, I specifically ask the client if they have any allergies to nuts, oils, scents, etc. I also never use scents without specific permission. All my clients are asked.

Now, the most invasive of forms ask things like surgeries and medications but very few ask about injuries and none that I've ever seen ask about degenerative conditions. (I had a boss with a rare kind of bone cancer that caused one of his vertabrae to collapse...you wouldn't want him on your massage table.) Mine asks about surgeries and medications, AND about any and all medical conditions - which would include a cancer or degenerative condition. Again, I am in a state that requires the health intake form, so every one I have seen has asked for this information. It is for the protection of the client. However, I would be absolutely shocked if someone came to me for a massage, KNOWING they had a condition so fragile that a vertabrae could collapse.

Anyway, back to my main point: All of the forms I've seen disclaim any medical benefit from a massage (though I feel that there are some), and point out that the CMT doesn't have a "medical" background. From this, the therapist doesn't have the background to evaluate the information being requested, so why invade someone's privacy in the first place? Just make the form consist of contact information, a list of known contraindications, maybe a disclaimer that the client should get an OK from his physician (if you're in a lawsuit-happy state) if there is any doubt about the safefy of massage for that particular client, and any other disclaimers that make you and your attorney feel better. Too many entities are requesting far more info than is necessary and that isn't a good thing. The info can be used in all sorts of undesirable ways...I know, I had my identity stolen twice in the last two years and all from info mined by information bureaus (not given by me) who, then, had their computer security breached.

My form does not disclaim any medical benefits. It states that massage therapists do not diagnose or cure...blah blah blah, but there are very well documented health benefits, and those will not be denied here!

I would never ask for any information that could result in identity theft! I don't ask for social security numbers or credit card numbers on the intake form. I also would never provide that to an MT who asked. But medical information is asked for because it is important to the client's health.

I have (rarely, but it has happened) had a client who did not want to give me the information. I explained the major reasons we ask - some medications will be flushed through the body faster, so dosage may need to be adjusted (diabetics may need to check their blood sugar sooner); I need to know if a client is taking blood thinners because of the risk of excessive bruising if I don't know this; some meds may have an "enhanced" effect when taken in conjunction with a massage; some conditions (such as congestive heart failure) may require that the massage NOT increase circulation (so I know to go with Shiatsu).....etc. Whether they choose to fully inform me is up to them, and I have no way of knowing if they choose not to. However, before I will massage a client, that intake form will be signed, saying that they *have* disclosed the information. That releases me from all liability if I have been misinformed or uninformed. That is a client's choice, and I respect your right to make that choice.

Again - it varies by state. Since you are in a state that does not require the intake form, and since you do not wish to provide the information - don't! If they aren't reading it, anyway, why waste the time and ink? I wouldn't, either!

 

[Andrea in La la Land]

best of the best

If you are actually getting the info in advance and looking up what you don't know...great! I've travelled on business and have had lower back pain for over 20 years so I have had a lot of massages from a lot of therapists (usually found on the AMTA site) and have NEVER had this experience. Most don't ask, the few that do don't seem to do anything useful with the information.

What I like about the therapist(s) (she owns a business that employs 4 other therapists) that I do see is that she actually talks to me before each session starts to find out what is going on. This takes place before any disrobing so that it is easy to point to specific areas if I don't know the names of the muscles involved (I do know many of the ones that have been a problem in the past but likely wouldn't know ones that are new problem areas). In the absence of this type of encounter, it would be useful (and I've NEVER seen a massage therapist do this) is to just provide a sheet of paper with front/back human drawing on it (chiropractors seem to love using these) and have the client mark on the drawing any problem areas and pains that travel could have the path indicated. Seems that this info would be more useful than what is generally requested...at least to having your client feel better (and that, in turn, would get you more repeat business).

BTW, I didn't mean to imply in ANY WAY, that massage is w/o medical benefits. I just know that the medical industry doesn't allow you to claim that massage treats any condition and I've seen that disclaimer on most of the information gathering forms. To the contrary, the first person (of chiropractors, MDs, and massage therapists) who correctly identified and improved my lower back pain was a massage therapist (who happened to also be a nurse and came from a family of chiropractors). She was so good I genuinely hope she isn't starving in the street back in CA (she actually fixed me in one visit for something I'd been seeing chiros and MDs on for years)...strange massage techniques (massage in some unusual postures, some even sitting up) but they sure worked well!

George

 

[gretchen]

best of the best

What I like about the therapist(s) (she owns a business that employs 4 other therapists) that I do see is that she actually talks to me before each session starts to find out what is going on. This takes place before any disrobing so that it is easy to point to specific areas if I don't know the names of the muscles involved George

Again....I don't know where you're going for your massages, but this is standard not only at our clinic but at almost any place I've gone for massage. We ALWAYS have a discussion with the client before the massage (or any disrobing) takes place. I can't imagine doing a massage without first doing this??

I know that there are exceptions to the rule, but like I said in my experience the therapist talking 1st to the client is the norm rather than the exception.

Angie

 

[Jane S]

there is no law in florida that requires an intake form... unless of course, you're doing medical and want insurance reimbursement.

Actually, this may have changed??

One of our receptionists is currently in school for massage and she was told that we are required to do intakes and keep the records for a period of 7 years afterwards. We told her that wasn't true and when she asked her teacher she was told that years ago that was the case but that the regulations had changed. She was told that sometime around the time that we went from being regulated by the DPR to the AQHC (or whatever those initials are now?? haha I'm still half-asleep) that the rules changed.

I sent an email to the Board of Massage to find out which was correct and of course never received a response from them. So....I'm not sure what the answer is??? When I went to school eons ago, we were taught that while we weren't required to do intakes and keep soap notes we should for the safety of our clients. Now, the same school is teaching that it's required.

t017
Angie

 

[ACWN]

t017 hmmm

i'll try to check on that moogie.

i think i reread chapter 480 recently and didn't see anything. and i'll admit, i don't know chapter 456 as well as i should. i was looking into FAC64b7 for the change in the draping law when the "sans-draping" thread came up, but i didn't read it entirely.

where's all our florida peeps?

 

[Tayler F]

best of the best

In the absence of this type of encounter, it would be useful (and I've NEVER seen a massage therapist do this) is to just provide a sheet of paper with front/back human drawing on it (chiropractors seem to love using these) and have the client mark on the drawing any problem areas and pains that travel could have the path indicated.
George

George, I do this, and it was the way I was trained to take my SOAP/CARE notes in school. I hand my client a highlight marker and ask them to color in the areas that are bothering them the most... so I can see where their pain is and if it refers to other areas. I like to call it, "Color My Pain" and it usually gets a smile out of the client before the session too. We realize the person's not going to be "the same" every time they come. That's why my intake form says they need to inform me if their health has changed since their last treatment.
Sorry you've rarely been experiencing this irish-george, but I sorta thought it was the norm! Health intake, informed consent, treatment notes are required by state law in WI and state law requires us to keep their information for 5 years.

 

[honeybflyy21282]

I was trained the same Maestra. We have a graphic of a body on our SOAP note forms.

 

[tatooedpriestess]

background info on experience(s)

maestra,

I like a therapist with a sense of humor!!! But I really think you should be handing out those "four packs" of crayons and tell 'em to use bright colors for the most painful areas and dull colors for dull pains.

Most of the massages I've received were in California and Michigan. At least when I left California (about 5 years ago), massage wasn't licensed at the state level. It was up to each individual local government to decide what they would require and about all that was required was to pay a fee and pass a background check (mostly to verify that the applicant wasn't a sex worker). There was no requirement for any sort of certification and most communities, if they had any educational requirement, required something as low as 100 hours of training. Needless to say, it took a major effort to find anyone competent in California. Here in Michigan, there currently is no state licensure and most communities don't require anything other than a business license, BUT for whatever reason, it IS a lot easier to find really good massage therapists (there is a school in Ann Arbor that turns out great ones). When I was initially looking for a therapist out here, I tried several (who had the right answers over the phone) and only one of them collected medical information (turns out she isn't the one I chose, she was good, but the one I selected was considerably better).

I am close enough to Canada, I have given a little thought to trying one of their RMT (registered massage therapists) as I understand something like 3500 hours of training is required to become one and they are considered to be in the health care field by the government and are sometimes prescribed by physicians there (more often than here). Here, in the US, it seems that there is a misconception in general about massage in that most people's reaction seems to be that a massage is for relaxation. Often, my massages include psoas and/or scalene work...let's see how "relaxed" they are after that!!!

George

 

[hello sunshinee. <3]

more info...

I guess I sort of have to respond to this...

I have a rather lengthy medically-oriented intake form. I REQUIRE my clients to fill it out and to be honest, because I need to know what they are on and what effect it might have. Almost ALL medications have undesireable and sometimes serious side-effects and while I may not know all the ins & outs of them all (it's impossible to keep up and hey...most of us have never had pharmacology!) it's important that I know a client is on a certain med so that if I come across a strange reaction or tissue quality I can look it up online. For example, some meds make tissues tight. I may massage those muscles till I'm blue in the face and a few sessions later, both me and my client may be at a loss as to why they're not getting any better...only to find that they're on some cholesterol-lowering med that makes the tissues tighter than a stretched rubber band! At least this way, I can look it up online if I feel a need to.

..I personally believe that it is only used for screening purposes (no one has ever requested the info in advance of the appointment nor has anyone taken over 30 seconds or so to look over it and I take several medications and have had several surgeries).

What kind of "screening" purposes? Please elaborate. And no, many of us are not going to request a lot of this info in advance. Some do, but for most, it just doesn't happen.

(About the fexofenadine reference...that is an antihistimine and if you are collecting that info, I'd expect you to know that

You're expecting too much. Again, most of us have never had pharmacology, nor are we glued to our TVs to find out the latest drugs being used and what their brand names are. I know lipitor and zoloft and a few others and that's about it. I haven't been to an MD since 1998 and I don't plan to go back unless I rip a tendon. I take care of everything else myself. I balk at the idea of taking prescriptions, so I'm not really up on them. I simply take the information for education purposes and to research something related to a client's session or progress if need be.

and ask if I am allergic to any scents or oils that I may come into contact with during the massage...in my situation, you could trigger an asthma attack with a scent or powder.)

I ask that anyway before applying anything. I have asthma, too. And everyone's asthma is different. I can do incense and essential oils just fine. Stress or cigarette smoke, on the other hand...

Now, the most invasive of forms ask things like surgeries and medications but very few ask about injuries and none that I've ever seen ask about degenerative conditions.

My forms ask about all of the above. Often, surgeries, accidents, injuries, etc, can cause trigger points in muscles that are reponsible for a lot of the pain out there. Some medications also make you more prone to trigger points. Trigger points go unnoticed and are rarely examined as a possible cause. Thus, I need to know if someone has had falls, car wrecks, physical trauma, etc.

Just make the form consist of contact information, a list of known contraindications, maybe a disclaimer that the client should get an OK from his physician (if you're in a lawsuit-happy state) if there is any doubt about the safefy of massage for that particular client, and any other disclaimers that make you and your attorney feel better. Too many entities are requesting far more info than is necessary and that isn't a good thing. The info can be used in all sorts of undesirable ways...I know, I had my identity stolen twice in the last two years and all from info mined by information bureaus (not given by me) who, then, had their computer security breached.

Couple of points here. First, such a brief form would be silly and not productive. Second, every state is sue-happy. Third, I bet very few ppl on this board know that the gov't actually owns your medical records. Bush signed that into law in mid-April 2001. Doctors can even sell information about your conditions and his findings and observations, in CONJUNCTION with personally identifiable information about YOU, WITHOUT your knowledge or consent, thanks *TO* HIPPA. Check out consumersunion.org for more info on the last point. And with 1 out of every 4 or so businesses getting sued EVERY YEAR, do you blame us for at least asking about what's in, and affecting, the body we're working on? I mean, after all, ppl are taking their clothes off in our presence...what's a little medical info? At least we're not going to sell it to other agencies like the MDs often do!

Just my thoughts...
~Jyoti

 

[arcticpuppet.]

best of the best

...she actually talks to me before each session starts to find out what is going on. This takes place before any disrobing so that it is easy to point to specific areas if I don't know the names of the muscles involved (I do know many of the ones that have been a problem in the past but likely wouldn't know ones that are new problem areas). In the absence of this type of encounter, it would be useful (and I've NEVER seen a massage therapist do this) is to just provide a sheet of paper with front/back human drawing on it (chiropractors seem to love using these) and have the client mark on the drawing any problem areas and pains that travel could have the path indicated.

Unless insurance reimbursement is involved, I don't have clients mess with the HIPPA consent and all the other paperwork that allows me to release only the necessary information required for reimbursement.. All client information, including SOAP notes, is considered confidential--I won't even discuss it with their spouse and they all reside under lock and key.

However, my intake form does include a little anterior and posterior person (with a blank area at the genitals) and I ask them to make an "X" over any place they DON'T want work as well as specify where they DO. Some make circles, draw arrows, color it in, whatever, but it's really obvious. Interestingly enough, they'll note on paper things they don't mention when I ask specifically in our pre-disrobing chat, so having a back-up has been really helpful. And of course, if I don't recognize any of the listed drugs I ask, "why do you take this? How much?" and reference further while they disrobe, if necessary.

The fact that every state has different requirements does make it difficult to know what is to be expected when we travel around, that's why we must speak up. When I had lomi-lomi in Hawai'i there was zero intake paperwork and I was expected to sit in a hot, steamy room for at least a half hour beforehand. This is a real migraine-trigger for me so I asked if I might open the window in the steam hut so my face could get cool air while my body stayed hot. It wasn't a problem and so I got my authentic steam-scrub-4 hands lomi-outdoor shower session and loved it. But nothing on even the most obsessive intake form would have disclosed that need unless I brought it up. BTW, the two blissful hours I was under their hands were the ONLY two hours my skull didn't hurt in ten days. Ah, the power of massage!!

 

[Dianne S]

Intake forms

Massage Therapists are not trained medical professionals in many states (some we are viewed as healthcare) BUT we are trained to not cause harm. A primary method is to ask a variety of questions which will provide us with information to provide the client with a safe massage. It is clear that you are well educated about your health, what effects your current health and what you want with your massage. Many many clients are not. Many clients have the basic understanding of there medications but may not know how something like increasing circulation via massage could be contraindicated for their condition.

Also, some insurance providers (Massage liability) require charting of each session. The intake is the begining of the charting process. An intake statement generally should cover what the scope of the MT practice is and that would be based on the laws of the State or the juristiction where they are licensed. Mainly, we want the client to know that if they have a serious health issue seeing a massage therapist is not a substitute for seeing a doctor, chiropractor, etc. That we do not and can not diagnose or prescribe.

For the privacy issue... just because a form asks for information there is no requirement to provide an answer to all the questions. You don't want to give the information, Don't! Even with medical intakes I do not answer all the questions. For example: Unless they are directly managing my insurance they do not get my SS#. I view an intake form as a way of providing information that the practioner (medical, dental, massage, what ever) feels they need BUT also a place for me to put my needs, even if there is no question for it on the form. The only caveat is, if we chose not to answer medical history questions then we accept risk and responsiblity for any issue that potentially could arise from the "unreported" information.


As for solicitations from massage therapists.... just say "no". Or write it on the intake! You can change your mind later.

 

[AnneC]

I'm just now seeing this thread. And I've got a little something to add as to why intakes/session notes are necessary. Liability.

My insurance is through ABMP and while the policy does not come right out and say that client history/intakes/soaps are required, it does STRONGLY SUGGEST that detailed client health history, session notes - to include session date and time be documented.

The therapist before me never did client intake or soaps. I can understand. They take a lot of time and they are a pain. To quote her, "I know these people and they would never sue me. I'm not worried about it." Uh-huh. Sorry, but I'm just not willing to take that risk.

I need to know if a client is on any medications, if they bruise easy, had surgeries, where they hurt, what they do for fun/work, sensitive to smells, allergic to anything (nuts and/or nut oils), etc. The last thing I want to do is hurt a client. "First, do no harm." If that means that I have to get a little nosey. And if the client isn't comfortable with that then maybe I'm not the therapist for them.