PLEASE READ BEFORE YOUR NEUROCOGNITIVE TEST APPOINTMENT
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- Felicity Fleming
- 7 years ago
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1 PLEASE READ BEFORE YOUR NEUROCOGNITIVE TEST APPOINTMENT In order to bring you the highest standard of concussion care, Impact Physiotherapy & Performance provides a full-service concussion testing and rehabilitative program. Our testers administer a supervised ImPACT assessment (computerized neurocognitive test). ImPACT is the most widely used and scientifically validated concussion assessment tool available ( The program measures multiple aspects of cognitive functioning in individuals, including: Attention span Working memory Sustained and selective attention time Response variability Non-verbal problem solving Reaction time In addition to ImPACT testing, Impact Physiotherapy & Performance recommends a thorough assessment of both balance and visual coordination, as these skills are often impaired following a concussion. (Please note that our visual screen in no way replaces the routine eye care provided by your regular eye doctor). We require a completed consent form prior to test administration. Please have this consent form along with the other forms you have been ed prior to your appointment. Please be aware that for the initial appointment, you may be here for 2 hours.
2 TIPS FOR SUCCESSFUL TEST TAKING Be sure to listen to all instructions carefully during the computer-based testing portion and give it your best effort. This will lessen the chance of you having to retake the test due to a less-than-optimal result. If during the test you find you do not understand the instructions, or if your computer freezes/test is interrupted, notify one of the test instructors right away. Let us know if you are sleepy, fatigued, rushed, distracted, emotionally distressed, or if you have been under the influence of intoxicants within the last 24 hours. We will reschedule your test for a day that you are feeling better. If you normally wear contact lenses or glasses on a full time basis, or if you have glasses specifically for reading, be sure to bring them to the test Give each task your BEST EFFORT A note on Neurocognitive Testing: On rare occasions, we do not obtain a successful result on the first test. Many computerized cognitive assessment tools have built-in quality control checks so that if performance is less than optimal or an athlete is intentionally trying to do poorly, the program will notify us. In these situations, we will ask you to complete a second test or have you return on a later date, as we do not want to underestimate your performance level. Often invalid attempts are a result of the testing environment (distraction by teammates, noise, etc.) or internal factors (lack of motivation, fatigue, frustration, or failure to understand the test principles). It is important to us that we obtain an accurate test, and for some, this requires repeat testing or a change in environment. If you have any questions regarding the process or concussion management in general, please do not hesitate to contact us! Impact Physiotherapy & Performance Team
3 Athlete Name: Date of Birth: / / (dd/mm/yy) Age: Parent Name: Phone: Team Name (if applicable): CONFIDENTIAL MEDICAL INFORMATION AND CONCUSSION HISTORY Please complete the following questions as fully and carefully as possible in order to help us effectively interpret the results of your baseline assessment. This information will remain strictly confidential. Concussion History: include month/year, how it happened, symptoms experienced, and length of recovery: No known concussions Do any of the following conditions apply? (please indicate) ADD/ADHD Clinical Depression/Anxiety Migraine Headaches Learning Disability Sleep Disorder Dyslexia Repeated one or more grade levels Received speech therapy Individual Education Plan (IEP) Motion Sickness / Car Sickness Visual Condition: Please indicate your level of academic performance: Below average (C/D Student) Average (B/C Student) Above Average (A/B Student) PLEASE REVIEW BELOW, SIGN, AND RETURN I hereby consent to the administration and supervision of a concussion baseline test by Impact Physiotherapy & Performance. I understand that baseline testing does not prevent concussive injuries, but allows healthcare professionals to better manage the injury should it occur. SIGNED PRINT NAME DATE
4 Confidential Patient Information Form Please complete the following questionnaire as fully and carefully as possible. Your answers will help us to process your file, determine the nature of your injury, and decide how best to assist you. This information will remain strictly confidential. PERSONAL INFORMATION Name: Date of Birth: / / (dd/mm/yyyy) Age: M/F Address: City: Postal Code: Telephone: (home) (work and/or cell) Emergency Contact: (name/relation) (Tel) Current Occupation: Name of Medical Doctor: (Tel) If Sport Related Injury: Sport: Team: How were you referred to the Shift Concussion Management Program? INJURY/DESCRIPTION OF COMPLAINT Give a Brief Description of your Injury/Complaint (Include how it was sustained): Date of Injury/Symptom Onset: For Head/Neck Pain: On the drawings to the right, please mark painful areas with symbols given: X Sharp & Stabbing Burning Pins & Needles S Dull Ache Numb Stiff & Tight Pressure # Throbbing Rate the following by circling a number: Level of pain now: None Worst ever felt Level of pain at its worst: None Worst ever felt Is your pain: constant intermittent/random activity dependent not sure
5 POST CONCUSSION SYMPTOM SCALE Please Indicate how you are feeling based on the last 2 days: 0 = NONE; 1-2 = Mild; 3-4 = Moderate; 5-6 = Severe Headache Sensitivity to Noise Nausea Irritability Vomiting Sadness Balance Problems Nervousness Dizziness Feeling more Emotional Fatigue Numbness or Tingling Trouble Falling Asleep Feeling Slowed Down Sleeping more than Usual Feeling Mentally Foggy Sleeping less than Usual Difficulty Concentrating Drowsiness Difficulty Remembering Sensitivity to Light Visual Problems Overall, is your pain getting better? worse? staying relatively constant? Have you sought medical evaluation for your current complaint before now? Yes No If yes, indicate type: Family MD Sport MD Emerge MD Walk-in MD Other Have you had any imaging for your current complaint (Xray, CT, MRI)? Yes No Please list any medications, or supplements (e.g. vitamins) you are currently taking (including over-the-counter): Do any of the conditions below apply to you? None ADHD Depression Migraine Learning Disability Sleep Disorder Anxiety Are you currently experiencing any ongoing medical conditions not listed? Have you had a routine eye exam in the last year? No Yes PAST HEALTH HISTORY Have you sustained any previous Concussions? No Yes If yes, indicate when they occurred and length of recovery: Please indicate any previous surgeries, hospitalizations, fractures, or traumas (other than concussion) (include year): FAMILY HEALTH HISTORY Have you or anyone in your immediate family had any of the following (please check those that apply): Heart disease High blood pressure Cancer Diabetes Stroke Other Disease
6 Name: Family Physician/ Location: Date of Birth: (M/D/YR) DR. Mailing Address / Postal Code: Home Telephone Number: Cell Phone Number: Emergency Contact and Phone number: Who referred you? o Doctor (Provide name) o Friend/ Family Member(Provide name) Referral Date: (M/D/YR) Where did you get our phone number? o Phone Book Business Card o Referral pad Internet o Other : CONSENT: I hereby consent to the assessment by the Physiotherapy staff of Impact Physiotherapy & Performance. Date: Signature: Witness: I hereby consent to the Plan of Care as explained by the Physiotherapist. I understand the possible risks and benefits of this treatment and that any changes to this plan of care will be discussed with me. I also understand that this clinic uses support personnel (trained Physiotherapy Assistants) to assist in carrying out some aspects of treatment but this is always done under the direction of the Physiotherapist. It is my right to withdraw my consent to treatment at any time. Date: Signature: Witness:
7 PRE-ASSESSMENT QUESTIONNAIRE 1. Do you or have you had any of the following problems? A) Heart Disease B) High/Low blood Pressure C) Lung Disease D) Diabetes E) Epilepsy F) Arthritis G) Tumor/cancer H) HIV/AIDS I) Hepatitis A, B, C J) Osteoporosis/Osteopenia 2. Do you smoke? Y N If yes, how many packs/day 3. Do you have vision or hearing impairments? 4. Do you have a pacemaker or metal implant? 5. Are you or do you suspect you are pregnant? 6. Have you had any surgery in the past? Please list: 7. Do you have any allergies? Are you allergic to latex? 8. Do you take any medications (please list. If you are taking a large list of medications, you can provide a copy of the list from your pharmacy)? Date: Signature of Client:
8 Client Information and Consent Form Impact Physiotherapy is a fee-for-service physiotherapy clinic. A client can access this option through extended health benefits or personal payment. It is our policy that accounts are paid on the date of your appointment. Invoices will be provided after each visit for submission to: Extended Health Insurance Plan Deductible Medical Expenses Cash, personal cheque, Visa, MasterCard and debit will be accepted for payment of accounts. Please provide us with the following information of your extended health benefit coverage (if applicable): Name of Ins. Company ID#: Percentage coverage: Policy/Plan # Dollar Limit: Who is the policy holder? If you are uncertain of the above information, please contact your Health benefit company. Unfortunately due to the confidentiality act, we are unable to do it on your behalf. Notice to insured extended health clients: If you receive a payment cheque from your company in your name, we unfortunately cannot accept your company cheque for payment towards your physiotherapy treatments. Our financial institution will not accept third party cheques. The payee on the cheque must be Impact Physiotherapy &Performance Inc. This means you are responsible for payment of your physiotherapy services. Cancellation Policy: You will be billed for missed appointments unless 24 hours advanced notice of cancellation is received. In the event that cancellation is not received in a timely fashion, a fee of $55 will be charged to your account. I hereby agree that I will pay for any missed or cancelled appointments at a fee of $55/incident should they occur. I hereby agree that I will pay for all services rendered to me by Impact Physiotherapy. I have read and understood all of the above statements and agree to adhere to them accordingly. I give consent to be assessed by the staff at Impact Physiotherapy. Client s Name (Print): Client s Signature: Date: Witness:
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27071 Cabot Rd., #101 Laguna Hills, CA 92653 (949) 588-7278 (949) 588-7331 Fax Patient Information Sheet [ ] Cash [ ] Insurance [ ] Medicare [ ] Personal Injury [ ] Auto Accident [ ] Workers PATIENT NAME
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Intake Form : Personal Information please print clearly Name: last first middle initial Home Address: Home Telephone: ( ) Cell Phone: E-Mail Address: Social Security #: of Birth: Age: Sex: M F Marital
PATIENT INFORMATION SPOUSE/PARENT/GUARANTOR INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION LAST NAME: FIRST NAME: MI: DAYTIME PHONE: DATE OF BIRTH: AGE: SEX: EMAIL ADDRESS: MALE MAILING ADDRESS: CITY: STATE: ZIP: FEMALE PHYSICAL ADDRESS (IF DIFFERENT THAN ABOVE): CITY: STATE:
FAIRBANKS PHYSICAL THERAPY
REGISTRATION PAPERWORK CHECKLIST If you wish, you can save time and simplify the registration process by completing the registration paperwork before you arrive. This checklist will help make sure you
NORTHERN EDGE PHYSICAL THERAPY
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Houston Healthcare Therapy Agreement
Houston Healthcare Therapy Agreement We will do our best to: Begin all sessions on time Explain your treatment program and progress to you Accommodate your schedule Be consistent with your therapist and
Welcome to Avida PT. The purpose of this letter is to provide you with some helpful information to prepare you for your visits to our facility.
AVIDAPT 1391 Dublin Rd, Columbus, OH 43215 614-487-9715 avidapt.com Welcome to Avida PT. The purpose of this letter is to provide you with some helpful information to prepare you for your visits to our
HAND & ORTHOPEDIC PHYSICAL THERAPY ASSOCIATES, A NJ P.C.
Consent for Care and Treatment I, the undersigned, do hereby agree and give my consent for HAND & ORTHOPEDIC PHYSICAL THERAPY ASSOCIATES, A NJ P.C., to provide Care and Treatment to considered necessary
Name Last) (First) ( (M.I.) Birth Date Social Security Age Sex: Home Address. City State Zip. Complaint/ Area to be treated Email Address
PLEASE PRINT CLEARLY : NEW PATIENT FORM Name Last) (First) ( (M.I.) Birth Social Security Age Sex: M / F Home Address City State Zip Complaint/ Area to be treated Email Address Home Phone ( ) Drivers Lic
1455 West Fair, Marquette, MI 49855 Phone - 906.226.0574 // Fax - 1.888.347.1135 // info@mqtrehab.com
To our valued patients, In order to speed up the registration process and begin your treatment as soon as possible, please complete the forms listed below and bring the proper documentation to your first
PATIENT HISTORY FORM
PATIENT HISTORY FORM If you are new to the office, have not been seen in over one (1) year, or are returning for a new problem, please complete this form in full. If there have been any changes since your
2. Timeliness: If you are more than 15 minutes late, we may ask you to reschedule your appointment.
Welcome to our clinic! Our goal at University of Wisconsin Hospital & Clinics is to offer the best possible care to our patients. We want to work with you to make that happen. To best work as a health
Primary Policy Holder Same as Patient Relationship to Patient: Name: Address: Apt# City: Patient Information. Name: Address: Apt# City: State: Zip:
Patient Information Name: Address: Apt# City: State: Zip: Sex: MALE FEMALE of Birth: Cell Phone: Home Phone: Work Phone: Email Address: Employer: Employer Phone #: Employer Address: Social Security #:
PATIENT REGISTRATION FORM PATIENT INFORMATION
Siepser Laser Eye Care PATIENT REGISTRATION FORM : PATIENT INFORMATION First Name Middle Initial: Last Name: Birth : Gender: Male Female Marital Status: SSN: Driver s License #: Address: City: State: Zip:
How To Pay For Care At A Clinic
WELCOME TO THE HUMAN PERFORMANCE AND REHABILITATION CENTERS, INC. Welcome to Human Performance and Rehabilitation Centers, Inc. The following information will give you a better understanding of our payment
DOB: // // Gender: Male Female. Home: Cell: Work:
Core Physical Therapy Clinics, LLC Paper Registration Form Patient Name Date DOB: // // Gender: Male Female Address: City State: Zip Code Home: Cell: Work: Email: Emergency Contact Employer: Name Insurance
Welcome to Central Florida Foot and Ankle Center
Welcome to Central Florida Foot and Ankle Center PATIENT INFORMATION Patient Name Address City State Zip Mailing Address City State Zip SS# DL# E-Mail Sex M F Age Birth Married Widowed Single Minor Separated
Accident / Injury Report
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PELED PLASTIC SURGERY HEADACHE HISTORY FORM
HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:
Physical Rehabilitation Center Outpatient Therapy Medical History Goals and Consent for Treatment
Goals and Consent for Treatment The Physical Rehabilitation Department is here to provide you with the highest quality of care. We treat every patient fairly and with respect, and make sure to protect
ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION
Outpatient Services 2381 Lawrenceville Road 609-896-9500 voice Patient Name: Account #: ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION Your first day of outpatient
REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: DATE OF BIRTH: / / AGE: SEX:
REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: E-MAIL ADDRESS: OCCUPATION: DATE OF BIRTH: / / AGE: SEX: SOCIAL SECURITY NUMBER: MARITAL STATUS: