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)
Patient relationship to Insured
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
Insured Name (Last, First, Middle Initial) (required)
Insured Address (Street)
(City, State, Zip)
Insured Date of Birth (MM/DD/YYYY)
Name of Primary Insurance Company
Name of Secondary Insurance Company
Referring Physician Name
Referring Physician Address (Street)
(City, State, Zip)
Primary Physician Name
Primary Physician Address (Street)
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
Does the pain wake you up at night?NoEvery NightOccasionallyRarely
On a scale of 0-10:
Please rate your CURRENT level of pain: ---012345678910
Please rate your WORSE level of pain in the last 24 hours: ---012345678910
Please rate your BEST level of pain in the last 24 hours: ---012345678910
What are your goals?
When do you expect it to get better?
GENERAL HEALTH SCREENING QUESTIONNAIRE:
Please add comments as needed.
Heart Condition YesNo
Do you have a pacemaker? YesNo
High Blood Pressure YesNo
Circulation/Vascular Problem YesNo
Do you have an asthma inhaler? YesNo
Emphysema or Bronchitis YesNo
Chemical Dependency / AlcoholismYesNo
Thyroid Condition YesNo
Low Blood Sugar YesNo
Multiple Sclerosis YesNo
Other Neurological Condition YesNo
Rheumatoid Arthritis YesNo
Other Arthritic Condition YesNo
Fractured / Broken Bones 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
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:
AngiogramBiopsyBlood testBone ScanCT scanDoppler UltrasoundEchocardiogramMammogramMRIStress TestUrine TestX Rays
Has anyone in your immediate family (parents / siblings) ever been diagnosed with the following:
CancerHigh Blood PressureHeart ConditionMental IllnessArthritis / OsteoporosisAlcoholism / Chemical dependencyDiabetesKidney DiseaseStroke
Have you recently (6 months) noted any new or changes in the following:
Body weightDizzinessHeadachesWeakness / FatigueFever, Chills, SweatsNumbness or tinglingBowel / BladderVision / HearingCoughing
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:
Medical DoctorChiropractorDentistPsychiatrist / PsychologistPhysical TherapistAcupuncturistMassage TherapistHomeopath
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
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
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.
(Please specify if YES)
I am regularly taking blood thinning (anti-coagulation) medication.
(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
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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