I am seeking help for: Which is limiting me from: When and how did this issue begin? What makes it worse? What makes it better?

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1 Shine Integrative Physical Therapy Intake Form First name Middle Last Birthdate / / How did you hear about us? Address City State Zip Home phone Cell phone address Occupation Emergency contact Phone Relationship Referring physician Primary physician I am seeking help for: Which is limiting me from: When and how did this issue begin? What makes it worse? What makes it better? Please indicate where ALL of your symptoms are on the body charts below: Highest pain level /10 Lowest pain /10 Average pain /10 Since onset, are symptoms getting: better worse staying the same? How/why? 1

2 Since the beginning of your symptoms, have you had? Circle all that apply: Fatigue/weakness Numbness/tingling Night pain Weight change Fever/chills Loss of bowel /bladder control Dizziness/fainting Vision changes Ringing ears What other treatment have you had for this condition? Circle all that apply: Medication Physical therapy Massage Acupuncture Rest Ice Brace/tape Injection Orthotics Joint work Surgery Heat Dental/orthodontic procedure Other: Results or changes from these treatments? Why do you think these treatments did or did not help? Have you ever had any of the following conditions? Circle all that apply: Vision impaired Hearing impaired Dizziness Head injury/concussion Latex allergy High blood pressure Diabetes Stomach/GI issues Metal implant Pacemaker Incontinence Thyroid impaired Cancer Clotting disorder Heart issue Infectious disease Hepatitis/HIV Neurological issue Breathing disorder Arthritis (type) Other Does the pain wake you at night? no yes: lying still changing positions Have you had similar symptoms in the past? no yes: when? Have you had any of the following imaging/tests? X-ray/CT scan MRI other Result(s) of these tests: Physical activities at work/home: How would you describe your general health? How often do you exercise (beyond daily activities)? List ALL medications and supplements: List ALL past traumas, surgeries/operations and when they occurred: List any significant family medical history: What are your goals for treatment at Shine? Any other concerns or comments? 2

3 Shine Integrative Physical Therapy Financial Policy FOR PATIENTS WITH HEALTH INSURANCE Please read the insurance benefit booklet(s) that your insurance provided you to fully understand all waiting periods, frequency limitations, deductibles, and other exceptions/exclusions. Should your insurance plan or your insurance change, please inform us immediately. ALL CLIENTS: You are responsible for any deductibles, co-pays, co-insurance and any services not covered by your plan. Copays are due at the time of service. You are responsible for all amounts not paid by your plan. MEDICARE: Medicare has a financial limit of $1900 per year for outpatient physical therapy & speech therapy. Once that amount has been met, you will be responsible for all further payments during that calendar year. FOR PATIENTS USING OTHER TYPES OF PAYMENT WORKERS COMPENSATION (WC): We will bill your workers compensation carrier for your charges. In the event your claims are denied, you will become financially responsible for all treatment charges. Motor Vehicle Accidents (MVA): In the state of Oregon, we can only use a prescription from a physician, osteopath, or dentist (but not a chiropractor) for MVA claims. We will bill your automobile insurance provided you have a medical claim open. In the event your claims are denied, you will become financially responsible for all treatment charges. PERSONAL LIABILITY/LITIGATION: If you are working with an attorney for your MVA or WC claim, and are not yet to the point of settlement, our financial policy is: If your account balance reaches $500, we ask for 10% monthly payment. If your claim is partially or fully denied, you are to assume full responsibility for payments, a payment plan must be drafted within 10 business days from denial. NON-INSURED SELF-PAY: A time-of-service discount will be applied for paying your entire invoice on the day of treatment. Discounts do not apply to supplies or equipment. OUR BILLING PROCESS Claims are sent by your PT through Athena Health who submits them to your insurance company for reimbursement. Athena Health sends a statement to you after your insurance has processed the claim. This statement will be on your Patient Portal for optional online payment. For payments made in person, we accept cash, check, MC, Visa, and Discover. 3

4 Balances over 60 days will be subject to 2% monthly finance charge. Returned checks will be charged a $40 fee. Statements that are 90 days past due will be sent to collections. I hereby authorize my insurance benefits be paid directly to Shine Integrative Physical Therapy. I understand that I am financially responsible for all services. I agree that I am fully responsible for all charges incurred here and all terms and conditions listed above. Shine Integrative Physical Therapy Privacy Policy By signing below, I agree that I have reviewed the privacy practice (in the clinic lobby and at and agree to these conditions. Shine Integrative Physical Therapy Release of Information In order to provide the best care possible, we may need to discuss your case with your other health care professionals. I authorize release my medical records to the following: Name: Contact: Name: Contact: Name: Contact: Shine Integrative Physical Therapy Missed Appointment Policy We are committed to helping you with your rehabilitation and expect you to attend all scheduled appointments (emergency situations not withstanding). Failure to cancel any appointment less than 24 hours prior to the start time will result in a $45 fee. Insurance will not cover this fee. In instances of repeated non-compliance with scheduled visits, we reserve the right to discontinue care. By signing below, I agree to this policy. Shine Integrative Physical Therapy Patient Informed Consent I voluntarily consent to physical therapy treatment and services deemed necessary by my physical therapist and/or referring provider. I acknowledge that no guarantees have been made to me as to the results of the services at Shine Integrative Physical Therapy. It is this clinic s sincere intent to educate me on every process. If techniques that are being or plan to be used to address my symptoms are not understood fully or if I have any other questions or concerns about my care I understand that it is my sole responsibility to communicate with Shine. By signing below, I agree that I will communicate promptly and perform the prescribed activities to the best of my abilities. 4

5 PATIENT WORKSHEET NAME DATE TIME AM/PM Initial Visit Discharge Visit PROBLEM AREA (Please check one): Upper Extremity (A,D) Lower Extremity (B,F) Cervical/Thoracic (C,D) Lumbar (D,F) TMJ (C,E) FUNCTIONAL INDEX PART I: Answer all five sections in Part 1. Choose the one answer in each section that best describes your condition. WALKING Symptoms do not prevent me walking any distance. Symptoms prevent me walking more than 1 mile. Symptoms prevent me walking more than 1/2 mile. Symptoms prevent me walking more than 1/4 mile. I can only walk using a stick or crutches. I am in bed most of the time and have to crawl to the toilet. WORK (Applies to work in home and outside) I can do as much work as I want to. I can only do my usual work, but no more. I can do most of my usual work, but no more. I cannot do my usual work. I can hardly do any work at all (only light duty). I cannot do any work at all. PERSONAL CARE (Washing, Dressing, etc.) I can manage all personal care without I can manage all personal care with some increased Personal care requires slow, concise movements due to increased I need help to manage some personal care. I need help to manage all personal care. I cannot manage any personal care. SLEEPING I have no trouble sleeping. My sleep is mildly disturbed (less than 1 hr. sleepless). My sleep is mildly disturbed (1 2 hrs. sleepless). My sleep is moderately disturbed (2 3 hrs. sleepless). My sleep is greatly disturbed (3 5 hrs. sleepless). My sleep is completely disturbed (5 7 hrs. sleepless). RECREATION/SPORTS (Indicate Sport if Appropriate ) I am able to engage in all my recreational/sports activities without increased I am able to engage in all my recreational/sports activities with some increased I am able to engage in most, but not all of my usual recreational/ sports activities because of increased I am able to engage in a few of my usual recreational/sports activities because of my increased I can hardly do any recreational/sports activities because of increased I cannot do any recreational/sports activities at all. ACUITY (Answer on initial visit.) How many days ago did onset/injury occur? days PART II: Choose the one answer that best describes your condition in the sections designated by your therapist. A. UPPER EXTREMITY CARRYING I can carry heavy loads without increased I can carry heavy loads with some increased I cannot carry heavy loads overhead, but I can manage if they are positioned close to my trunk. I cannot carry heavy loads, but I can manage light to medium loads if they are positioned close to my trunk. I can carry very light weights with some increased I cannot lift or carry anything at all. DRESSING I can put on a shirt or blouse without I can put on a shirt or blouse with some increased It is painful to put on a shirt or blouse and I am slow and careful. I need some help but I manage most of my shirt or blouse dressing. I need help in most aspects of putting on my shirt or blouse. I cannot put on a shirt or blouse at all. REACHING I can reach to a high shelf to place an empty cup without increased I can reach to a high shelf to place an empty cup with some increased I can reach to a high shelf to place an empty cup with a moderate increase in I cannot reach to a high shelf to place an empty cup, but I can reach up to a lower shelf without increased I cannot reach up to a lower shelf without increased symptoms, but I can reach counter height to place an empty cup. I cannot reach my hand above waist level without increased B. LOWER EXTREMITY STAIRS I can walk stairs comfortably without a rail. I can walk stairs comfortably, but with a crutch, cane, or rail. I can walk more than 1 flight of stairs, but with increased I can walk less than 1 flight of stairs. I can manage only a single step or curb. I am unable to manage even a step or curb. UNEVEN GROUND I can walk normally on uneven ground without loss of balance or using a cane or crutches. I can walk on uneven ground, but with loss of balance or with the use of a cane or crutches. I have to walk very carefully on uneven ground without using a cane or crutches. I have to walk very carefully on uneven ground even when using a cane or crutches. I have to walk very carefully on uneven ground and require physical assistance to manage it. I am unable to walk on uneven ground. PATIENT WORKSHEET Therapeutic Associates, Inc. (Revised: 12/16/10) FORM C004

6 C. CERVICAL/TMJ CONCENTRATION I can concentrate fully when I want to with no difficulty I can concentrate fully when I want to with slight difficulty. I have a fair degree of difficulty in concentrating when I want to. I have a lot of difficulty in concentrating when I want to. I have a great deal of difficulty in concentrating when I want to. I cannot concentrate at all. HEADACHES I have no headaches at all. I have slight headaches which come less than 3 per week. I have moderate headaches which come infrequently. I have moderate headaches which come 4 or more per week. I have severe headaches which come frequently. I have headaches almost all of the time. READING I can read as much as I want without increased I can read as much as I want with slight I can read as much as I want with moderate I cannot read as much as I want because of moderate I can hardly read at all because of severe I cannot read at all. D. LUMBAR*/CERVICAL/UPPER EXTREMITY DRIVING I can drive my car or travel without any extra I can drive my car or travel as long as I want with slight I can drive my car or travel as long as I want with moderate I cannot drive my car or travel as long as I want because of moderate I can hardly drive at all or travel because of severe I cannot drive my car or travel at all. LIFTING I can lift heavy weights without extra I can lift heavy weights but it gives extra My symptoms prevent me from lifting heavy weights but I manage if they are conveniently positioned. (e.g. on a table) My symptoms prevent me from lifting heavy weights but I manage light to medium weights if they are conveniently positioned. I can lift only very light weights. I cannot lift or carry anything at all. E. TMJ TALKING I can talk without any increased I can talk as long as I want with slight symptoms in my jaws. I can talk as long as I want with moderate symptoms in my jaws. I cannot talk as long as I want because of moderate symptoms in my jaws. I can hardly talk at all because of severe symptoms in my jaws. I cannot talk at all. EATING I can eat whatever I want without I can eat whatever I want but it gives extra Symptoms prevent me from eating regular food, but I can manage if I avoid hard foods. Symptoms prevent me from chewing anything other than soft foods. I can chew soft foods occasionally, but primarily adhere to a liquid diet. I cannot chew at all and maintain a liquid diet. F. LUMBAR*/LOWER EXTREMITY STANDING I can stand as long as I want without increased I can stand as long as I want, but it gives me extra Symptoms prevent me from standing for more than 1 hour. Symptoms prevent me from standing for more than 30 minutes. Symptoms prevent me from standing for more than 10 minutes. Symptoms prevent me from standing at all. SQUATTING I can squat fully without the use of my arms for support. I can squat fully, but with symptoms or using my arms for support. I can squat 3/4 of my normal depth, but less than fully. I can squat 1/2 of my normal depth, but less than 3/4. I can squat 1/4 of my normal depth, but less than 1/2. I am unable to squat any distance due to SITTING I can sit in any chair as long as I like. I can only sit in my favorite chair as long as I like. My symptoms prevent me sitting more than 1 hour. My symptoms prevent me sitting more than 1/2 hour. My symptoms prevent me sitting more than 10 minutes. My symptoms prevent me from sitting at all. * Lumbar questions adapted from Oswestry. PAIN INDEX Please indicate the worst your pain has been in the last 24 hours on the scale below No Pain Worst Pain Imaginable PLEAS E DO NOT COMPLETE TH E FOLLOWING S ECTIONS O N FIRS T VI S IT GLOBAL RATING OF CHANGE With respect to the reason you sought treatment, how would you describe yourself now compared to your first treatment at our clinic? (Circle one) Very Much Worse Unchanged Completely Recovered WORK STATUS (check most appropriate) 1. No lost work time 2. Return to work without restriction Work days lost due to condition: days 3. Return to work with modification 4. Have not returned to work 5. Not employed outside the home I am aware that the information gathered on this form may be used anonymously for research or publication. Please initial: