New Patient Intake form

PATIENT INFORMATION:

Your Name (Last, First, Middle Initial)

Your Email (required)

Your Home Phone Number (required)

Your Cell Phone Number

Your Work Phone Number

Your Date of Birth (MM/DD/YYYY) (required)

Your Age (required)

Sex
MaleFemale

Marital Status
MarriedSingleOther

Patient relationship to Insured
SelfSpouseChildOther

Your Address (Street)

(City, State, Zip Code)

Emergency Contact Person / Phone Number

Responsible Party Information (if different from above)


How did you hear about us?

Previous patientReferred by MDAdvertisementYMCA staffCommunity eventHome care staffOther




INSURANCE INFORMATION:

Insured Name (Last, First, Middle Initial) (required)

Insured Address (Street)

(City, State, Zip)

Insured Date of Birth (MM/DD/YYYY)

Insured Age

Sex
MaleFemale

Name of Primary Insurance Company

Name of Secondary Insurance Company




M.D. INFORMATION:

Referring Physician Name

Referring Physician Address (Street)

(City, State, Zip)

Phone number

Fax number


Primary Physician Name

Primary Physician Address (Street)

(City, State, Zip)

Phone number

Fax number



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REASON FOR VISIT:
What is the reason for your visit?

When did this problem happen?

How did this problem happen?

BODY PART INVOLVED:
HeadNeckRight shoulderLeft shoulderRight elbowLeft elbowRight wrist handLeft wrist handMid backLower backPelvisRight hipLeft hipRight kneeLeft kneeRight ankleLeft ankleRight footLeft foot

What makes it better?

What makes it worse?

Associated symptoms and pain description (check all that apply):
ClickingSwellingLockingBucklingStiffnessWeaknessDifficulty walkingDifficulty with stairsConstantIntermittentSharpBurningDeep acheStabbing painRadiatingNumbnessTinglingPins and needlesDecreased balance / stabilityFalls
Other:

Does the pain wake you up at night?NoEvery NightOccasionallyRarely

On a scale of 0-10:
Please rate your CURRENT level of pain:
Please rate your WORSE level of pain in the last 24 hours:
Please rate your BEST level of pain in the last 24 hours:

What are your goals?

When do you expect it to get better?




GENERAL HEALTH SCREENING QUESTIONNAIRE:
Please add comments as needed.

Cancer                          YesNo  
Heart Condition                 YesNo  
Do you have a pacemaker?        YesNo  
High Blood Pressure             YesNo  
Circulation/Vascular Problem    YesNo  
Asthma                          YesNo
Do you have an asthma inhaler?  YesNo  
Emphysema or Bronchitis         YesNo  
Chemical Dependency / AlcoholismYesNo  
Thyroid Condition               YesNo  
Diabetes                        YesNo  
Low Blood Sugar                 YesNo  
Multiple Sclerosis              YesNo  
Stroke                          YesNo  
Other Neurological Condition    YesNo  
Rheumatoid Arthritis            YesNo  
Osteoarthritis                  YesNo  
Other Arthritic Condition       YesNo  
Osteoporosis                    YesNo  
Fractured / Broken Bones        YesNo  
Depression                      YesNo  
Hepatitis                       YesNo  
Tuberculosis                    YesNo  
Anemia                          YesNo  
Kidney Disease                  YesNo  
Epilepsy or Seizure             YesNo  
Ulcer or Stomach Problems       YesNo  
Skin Conditions                 YesNo  
Prostate Problems               YesNo  
OB / GYN Problems               YesNo  
Complicated Pregnancy / DeliveryYesNo  
Other   



Please describe any SURGERIES or HOSPITALIZATIONS (and approximate years) that you have ever had:



Please list ANY INJURIES that you may have had WHICH REQUIRED MEDICAL ATTENTION (when and how long?):



Please list any PRESCRIPTION MEDICATIONS you are taking:


Check any NONPRESCRIPTION MEDICATIONS that you are currently taking:


Within the past year, have you had any of the following tests? Check all that apply:

Other:


Has anyone in your immediate family (parents / siblings) ever been diagnosed with the following:

Other:


Have you recently (6 months) noted any new or changes in the following:


Please check any of the following healthcare providers who are currently providing you care, or have provided you care in the past 3-6 months:

Other:



Are you, or do you think that you may be pregnant? YesNo
Do you have any religious beliefs that might affect your care? YesNo
If you were to lose consciousness under our care, would you want lifesaving measures (CPR)
to be performed to save or resuscitate you? YesNo
Are you allergic or sensitive to latex? YesNo
Are you allergic to shellfish or iodine? YesNo
How much coffee / beverages with caffeine do you think you drink per day? Cups
How many packs of cigarettes do you smoke a day? Packs
How many glasses of wine or beer do you consume in an average sitting? Glasses
How many days per week do you use illicit drugs?


During the past month have you been feeling depressed, down or hopeless? YesNo
During the past month have you had little interest or pleasure in doing things? YesNo
Do you ever feel unsafe at home or has anyone ever hit or tried to injure you in anyway? YesNo


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CONSENT TO TREATMENT AND FINANCIAL POLICIES:


FOR PATIENTS WITH PRIVATE INSURANCE:
I understand that payment for service is due at the time of service. I am responsible for seeking my own reimbursement form my insurance company, flexible spending account or health saving account. I am responsible for understanding the limits and requirements of my insurance policy including need for referrals, prescriptions, deductible, and copayments. I agree that Professional Physical Therapy & Training, LLC may discuss my case with my physician or other practitioner for the purpose of my care only. It is my right as a patient to understanding the treatment, which I am participating in and can refuse participation at any time. By checking the box below, I consent to physical therapy treatment.
FOR PATIENTS WITH MEDICARE INSURANCE:
I request that payment of authorized benefits be paid on my behalf to Professional Physical Therapy & Training, LLC for services furnished to me by the Professional Physical Therapy & Training, LLC. I authorize any holder with medical information about me to release to Medicare or other insurance any information needed to determine these benefits payable for related services. I understand that Professional Physical Therapy & Training, LLC accepts assignment of Medicare, which pays 80% of the allowable charges for service. I will be responsible for the remaining 20 percent. I agree that Professional Physical Therapy & Training, LLC may discuss my case with my physician or other practitioner for the purpose of my care only. It is my right as a patient to understand the treatment, which I am participating in and can refuse participation at any time. By checking the box below, I consent to physical therapy treatment.
I HAVE READ AND UNDERSTAND THE ABOVE STATEMENTS




CANCELLATION POLICY:
Professional Physical Therapy and Training strives to provide its patients with exceptional care. All our sessions are one hour in length. Our therapists spend that time one-on-one with each client. Not attending your appointment inhibits our ability to help you achieve your goals and adversely affects our ability to function financially. By checking the box below you understand that you MAY be charged half of the visit fee for cancellations without twenty-four hours notice, or you WILL be charged the entire visit fee for an appointment no show.
I HAVE READ AND UNDERSTAND THE ABOVE STATEMENT



Graston Technique Consent
Please read the Graston Technique Information page prior to answering the following questions:

Do you bruise easily?                                YesNo
Do you bleed for a long time after you get cut?      YesNo
Are you taking blood thinners or anticoagulants?     YesNo
Do you take Aspirin on a regular basis?              YesNo
Do you take cortisone on a regular basis?            YesNo
Have you ever had inflamed veins or blood clots?     YesNo
Do you have any surgical implants?                   YesNo
Do you have diabetes or kidney disease?              YesNo
Do you have uncontrolled blood pressure?             YesNo
Do you currently have any infections?                YesNo
Are you allergic to bees wax?                        YesNo

BY CLICKING BELOW, I HEREBY ATTEST THAT I UNDERSTAND THE RISKS OF THIS PROCEDURE AND GIVE MY FULL CONSENT FOR THE TREATMENT IF INDICATED BY MY THERAPIST.
I consent to the Graston Technique



Dry Needling Consent
Please read the Dry Needling Information page prior to answering the following questions:

I have a fear of needles.                     YesNo
I have a genetic bleeding disorder.           YesNo
            (Please specify if YES)            
I have a history of a blood disorder that can be transmitted to another person.
                                              YesNo
            (Please specify if YES)            
I am regularly taking blood thinning (anti-coagulation) medication.
                                              YesNo
            (Please specify if YES)            
I am regularly taking pain relievers.         YesNo

BY CLICKING BELOW, I HEREBY ATTEST THAT I UNDERSTAND THAT THIS PROCEDURE IS NOT ACUPUNCTURE AND I GIVE MY FULL CONSENT TO HAVE THE PROCEDURE OF DRY NEEDLING PERFORMED ON ME IF INDICATED BY MY THERAPIST.
I consent to Dry Needling



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BY CLICKING AND DATING BELOW, I HEREBY ATTEST THE ABOVE INFORMATION IS CORRECT.
I HAVE SUBMITTED ALL THE ABOVE INFORMATION CORRECTLY. DATE:

BY CLICKING BELOW, I INDICATE THAT I AM COMPLETING THIS FORM FOR A MINOR (PATIENT IS LESS THAN 18 YEARS OF AGE.
I AM COMPLETING THIS FORM FOR A MINOR




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