My name is Daniel Ruscigno, and my company ClinicSense
Transcript of My name is Daniel Ruscigno, and my company ClinicSense
My name is Daniel Ruscigno, and my company ClinicSense
helps massage therapists automate their administrative tasks
(scheduling, intake forms, note-taking, invoicing, and more) so
they can spend less time on paperwork and more time doing
the things they love.
When you start using clinic management software you will:
- Save yourself time from tedious admin work
- Feel the relief of being more organized
- Put more money into your pocket
But, just in case you’re not yet using ClinicSense, I wanted to
find a way to provide you with some value as well :) On the
following pages you will find paper templates for:
• Intake form
• Consent form
• COVID-19 Prescreening form
• SOAP note for pain
• SOAP note for relaxation
• Sensitive area consent form
• Cancellation policy
• Gift certificate promotion template
• Gift certificate template
• Retention email template
• Introduction letter to other healthcare professionals
subjective
Client Name Date
Therapist Name Duration Of Treatment
Sensation of pain:
Dull Cold
Sharp Burning
Tender Aching
Itching Sensitive
Cramping Radiating
Throbbing Shooting
Tingling Pressure
Stiff
Other
Was there a specific incident that cause this pain?
Motor vehicle accident Fall
Slept funny Work related
Sports/exercise
Other
Intensity of pain: (circle one)
When did the pain start:
Primary area of pain:
Adhesion Spasm
Rotation Inflammation
Pain Trigger point
Tender Point Elevation
Hypertonicity
Time pattern of pain
Constant (pain does not change)
Intermittent (intensity doesn’t change but comes & goes)
Variable (intensity changes throughout the day)
Pain/discomfort is brought on or made worse by...
Pain/discomfort feels better with…
Does this pain prevent you from participating in…
Work Leisure activities
Sports/exercise Sleep
Other
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Have you seen other practitioners about this issue?
Massage therapist Physical therapist
Chiropractor Physician
Other
sOAP NOtes
Spine
Normal
Lordosis [ mild moderate severe ]
Kyphosis [ mild moderate severe ]
Scoliosis [ mild moderate severe ]
RaNge Of mOTION
Area
Full range Moderate restriction
Slight restriction Severe restriction
Area
Full range Moderate restriction
Slight restriction Severe restriction
Areas treated
Back
Neck
Shoulders
Feet
Hip area
Other
Techniques used
Swedish
Deep tissue
Hot stone
Intra-oral
Shiatsu
Other
Abdominals
Chest
Face
Arms
Legs
Reflexology
Trigger points
Stretching
Hydrotherapy
Thai massage
PalPaTION
Area
Tension [ mild moderate severe ]
Texture [ pliable adhesive fibrotic ]
Tenderness [ mild moderate severe ]
Temperature [ normal increased decreased ]
Area
Tension [ mild moderate severe ]
Texture [ pliable adhesive fibrotic ]
Tenderness [ mild moderate severe ]
Temperature [ normal increased decreased ]
Pelvis
Normal
Tilt [ mild moderate severe ]
Twist [ mild moderate severe ]
Protract [ mild moderate severe ]
Retract [ mild moderate severe ]
Shoulders
Normal
Tilt [ mild moderate severe ]
Twist [ mild moderate severe ]
Protract [ mild moderate severe ]
Objective
treAtmeNt
POSTuRe aSSeSSmeNT
AssessmeNt PlAN
How did the client respond to treatment? Treatment plan and self-care recommendations:
Informed consent received
sOAP NOtes Page 2 of 2
Client Name Date
Therapist Name Duration Of Treatment
PRE-TREATMENT
Thinking about the past week, how would you rate your level of stress?
Not at all stressed
Somewhat stressed
Very stressed
Thinking about the past week, how would you rate your quality of sleep?
Excellent
Good
Fair
Poor
Additional information provided by the client:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Therapist observations and results of physical examination:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
POST TREATMENT
How would you rate your current level of relaxation?
Not at all relaxed
Somewhat relaxed
Very relaxed
Additional information provided by the client:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
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SOAP NOTE fOr rElAxATiON
TREATMENT PLAN
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Page 2 of 2SOAP NOTE fOr rElAxATiON
Date of initial visit How would you rate your general health?
Excellent Good
Fair Poor
Have you had a professional massage before?
Yes (Date of last treatment)
No
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First Name Date of birth
Last Name Referred by
Email Address Mobile Phone #
Home Phone # Work Phone #
Street Address City
State Zip Code
Emergency contact name Physician’s name
Emergency contact relationship Physician’s phone #
Emergency phone #
List current medications & the conditions they are treating
Please tell us about any allergies or hypersensitivities Reason for initial visit
List any major accidents or surgeries (including dates)
intake form
CardiovasCular
High blood pressure Low blood pressure
Heart attack Stroke
Heart disease Poor circulation
Phlebitis / varicose veins Pacemaker
Hemophilia
Chronic congestive heart failure
Family history of cardiovascular problems
skin & infeCtions
Hepatitis HIV / AIDS
Herpes Tuberculosis
Lyme disease Infectious skin conditions
other Conditions
Cancer Diabetes
Unexplained weight loss Digestive conditions
Fibromyalgia Chronic fatigue syndrome
Depression Anxiety
Psychiatric disorder
Other conditions
head neCk
Headaches / migraines Vertigo / dizziness
Ringing in ears Hearing loss
Vision problems Vision loss respiratory
Asthma Shortness of breath
Chronic cough Bronchitis
Emphysema Sinusitis
Frequent colds Smoker
Family history of respiratory difficulties nervous system
Sensory loss / change Numbness / tingling
Sciatica Epilepsy
Seizures Multiple sclerosis musCuloskeletal system
Arthritis Family history of arthritis
Osteoporosis Tendonitis
Bursitis Jaw pain (TMJ)
Pins / plates / wires / artificial joint
reproduCtive
Pregnant Given birth
Gynecological problems
intake form Page 2 of 2
I hereby certify that the above information is accurate and true
Signature: ______________________________________________________________________________ Date: _________________________
CONSENT FORM
It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage.
I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis.
I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.
I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment.
Treatments may be covered by extended health care plans. I understand that it is my responsibility to confirm the exact details of my coverage.
Signature: __________________________________________ Date: _________________________
I, ________________________ (name), have requested assessment and/or treatment by this therapist
________________________ (name) for treatment of the clinically relevant areas indicated below (please initial):
______ Chest Wall Muscles (not including breasts)
______ Breast (s)
______ Buttocks (gluteal muscles)
______ Upper Inner Thigh(s)
List Clinical Indication: _____________________________________________________________
The therapist has explained the following to me and I fully understand the proposed assessment and/or treatment: • The nature of the assessment, including the clinical reason(s) for assessment of the above area(s) and the draping methods to be used • Theexpectedbenefitsoftheassessment • The potential risks of the assessment • The potential side effects of the assessment • That consent is voluntary • That I can withdraw or alter my consent at any time.
I voluntarily give my informed consent for the assessment and/or treatment as discussed and outlined above.
Client Name (print): _____________________________________________________________
Client Signature: _________________________________________Date: _________________ Ongoing Treatment:I am aware that the treatment of the above indicated area(s) is part of a treatment plan which has been discussedwithmebymytherapist.Iconfirmthat,onthefollowingdate(s),thetherapisthasreviewedthe treatment plan and I provide my informed consent.
Client Signature: ____________________________________Date: _______________
Client Signature: ____________________________________Date: _______________
Client Signature: ____________________________________Date: _______________
Client Signature: ____________________________________Date: _______________
CONSENT TO ASSESSMENT & TREATMENT OF SENSITIVE AREA
Signature
Date Time
I agree that I am not currently experiencing any of these symptoms:
• Cough •Shortnessofbreathordifficultybreathing • Fever •Chills • Sore throat •Newlossoftasteorsmell
Please note: Otherlesscommonsymptomshavebeenreported,includinggastrointestinalsymptomslikenausea,vomiting, or diarrhea.
HaveyoutestedpositiveforCOVID-19? HaveyouknowinglybeenexposedtosomeonewithCOVID-19? Haveyourecentlytraveledtoanareawithahighinfectionrate? Haveyoubeeninanareawheresocialdistancingwasnotproperlyobserved? Haveyoubeentoanursinghome?
Ifyouhaveexperiencedanyoftheabove,pleaseprovidemoredetailastodatesofinfection,contactwithpersonexposedetc.
COVID-19 PRE-SCREENING
YES NO
Please be aware of our 24-hour cancellation policy.
Because it is difficult to fill a cancelled appointment without sufficient notice,
appointments cancelled without 24 hours notice and missed appointments will be charged
a fee of $_______.
If you need to cancel your appointment, please call or email us at least 24 hours in advance.
We can be reached at _____________________or via email at ____________________________.
Thank you!
I,_____________________________________________, have read and agree to the above policy.
cancellation policy
Signature _____________________________________________________ Date ________________________
RETENTION EMAIL TEMPLATE
Good morning ___,
I hope that you are doing fantastically well!
I noticed that it’s been _____ months since your last appointment and wanted to reach out in case any aches or pains have crept up in that time, or maybe you’re just looking to treat yourself to a little bit of “me” time and schedule a relaxation massage.
I’d love to see you soon. If you’d like to book an appointment, here’s a link to my online scheduling so you can see my availability: ____________.
Have a great day!
GIFT CERTIFICATE PROMOTION EMAIl TEMPlATE
Good morning __________________________,
I hope your day is off to a great start…and I’m also hoping that my email makes it a little bit better!
I’m emailing today to let you know that I’m offering ________% off on gift certificates until ____________________. So if you’re looking to treat yourself, a family member, or a friend, this is a great chance to lock in some savings.
If you’d like to take advantage, you can conveniently buy a gift certificate online and it will be emailed to you. Here’s the link to my online gift certificates:______________________
Have a great day and hope to see you soon!
Gift certificate teMPLate
GIFT CERTIFICATEClinic Name: _____________________________________________________________________
To: ______________________________________________________________________________
From: ____________________________________________________________________________
Amount: _________________________________________________________________________
Date Issued: ______________________________________ Expiry: _______________________
Authorized Signature: _____________________________________________________________
GIFT CERTIFICATEClinic Name: _____________________________________________________________________
To: ______________________________________________________________________________
From: ____________________________________________________________________________
Amount: _________________________________________________________________________
Date Issued: ______________________________________ Expiry: _______________________
Authorized Signature: _____________________________________________________________
Copy attributed to AMTA
IntroductIon letter
Clinic Name: ______________________________________________
Clinic Address: ____________________________________________
Date: ______________________________
Dear Dr. ___________________________,
My name is ________________, and I am a licensed massage therapist. [I am new to your area/We are sharing a patient for the first time], and I wanted to tell you a little bit about myself and the kind of work I do in the hope that we may work together. It is my intention to support your health care plan and to provide quality care to your patients.
I have experience in actively participating with health care teams and am able to communicate through standard forms of documentation. Enclosed are sample copies of my charting and report writing style. I am committed to keeping my referring physicians apprised of their patients’ progress.
My specialty is [headaches]. I have attended advanced study courses on this condition and have taken a particular interest in [headaches related to whiplash trauma]. Recently published results of research regarding the efficacy of massage on patients with headache pain report [cite research and summarize its results]. I am also highly skilled in [working with a variety of musculoskeletal dysfunctions].
I have enclosed a brochure that describes my practice and services, and the fees for various services. I have included information about the benefits of massage therapy specific to conditions your patients might experience.
Professionalism, communication, and quality health care are my strengths. [Please call me if you wish to /I will call your office in two weeks to] discuss any of this information in more depth, or if any of your patients have the need for an exceptional massage therapist.
I look forward to working with you.
Yours in health,
Once you’re ready to take the next step in your business, I’d like to invite you to join ClinicSense.
We’re generally helping save an hour per day from admin work, which allows you to spend more
time with your clients or on growing your business.
We offer a 14-day free trial (with no credit card required) so you can see how ClinicSense works.
START FREE TRIAL
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