Physiotherapy Intake Form. Patient Information
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- Julianna Poole
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1 Physiotherapy Intake Form Patient Information Name Home Phone Date of Birth Work Phone Address Cell Phone City Postal Code address AHC # What is your primary purpose for attending today/what body region is bothering you? Occupation Family doctor Doctor s phone # Emergency contact # Relation How did you find us? Consent for Treatment Physiotherapy treatment techniques may include, but are not limited to: manual techniques including spinal manipulation, electrotherapeutic modalities and exercise as well as other techniques such as acupuncture and intramuscular stimulation (IMS). A number of these may be recommended during your program. At any time your consent can be withdrawn. If you have any specific concerns regarding your sessions at Whyte Ave Sport and Spine, please discuss them with your therapist. By signing below I acknowledge I will be receiving an assessment and treatments for physiotherapy and accept the responsibility for the fees associated with these sessions. Signature of patient (or guardian if patient under the age of 18) Date Signature of Witness Date 1
2 Billing and Office Policy At Whyte Ave Sport and Spine, there is no physiotherapy coverage through Alberta Health Services (AHS) or Workers Compensation (WCB). Physiotherapy treatment may be covered by either extended health insurance plans or motor vehicle accident insurance. Please let us know which method of payment will be used upon first assessment. Because benefit plans vary, please check the details of your coverage. It is the patient s responsibility to understand any limitations to coverage. Agreement for Payment and Fees I understand that payment for services received at the clinic is my responsibility. While coverage may be available at other clinics, there is no coverage for physiotherapy by the government (AHS) or the Workers Compensation Board (WCB) at this clinic. I understand that the fees per visit for this service are: Initial assessment and treatment: $110 Follow up treatments: $85 Extended treatment/multiple body site $100 I understand the fees have been explained to me. Signature Late Cancellation and No Show Policy In order to offer you quality service, we require 24 hours notice of any changes to your appointment. This 24 hour notice allows us to offer your appointment to someone else on our waiting list. If you do not arrive for an appointment and do not call outside of 24 hours you will be charged for the full cost of the appointment. Your cooperation is greatly appreciated. Signature (if patient is under the age of 18, guardian must sign for them) Witness DIRECT BILLING POLICY At Whyte Ave Sport and Spine we will do our best to provide direct billing for your services. It is the patient s responsibility to know their benefit plan and monitor the amount of coverage they have. In the event that coverage is denied or exhausted, the individual is responsible to pay any fees for services received. I understand (initial): Provider Name: Policy Number: Plan: 2
3 MOTOR VEHICLE ACCIDENTS (MVA): Insurance Company: Policy #: Claim#: Date of Accident: I understand that if my Motor Vehicle Accident Claim is NOT accepted, I am responsible for any payment/fees related to my treatments (initial): Health and Lifestyle Information In order for your therapist to treat you in a safe manner, please provide us with the following information on your health and lifestyle. Do not worry about the questions that you are unsure of; your physiotherapist will go over them with you. Are you pregnant? Yes No Pregnancies and deliveries (number and year) Do you have a pacemaker? Yes No Name of other Healthcare Providers you are seeing for your problem: Have you ever suffered or do you currently suffer from the following conditions? Digestive problems Headaches Insomnia HIV/AIDS Neurological (i.e. Stroke, Seizures, Epilepsy) Bladder Incontinence Anxiety or Depression Orthopedic problems (including fractures and arthritis) Allergies Major traumas (accidents, falls) Osteoporosis Inflammatory illness Major infections Diabetes Respiratory problems/smoker Cancer Cardiac problems (high blood pressure, heart disease) or pacemaker Unexplained weight loss List details for any checked above: 3
4 Health and Lifestyle Information List of ALL previous surgeries and the year they were performed: List of ALL previous injuries (eg. Car accidents, falls, concussions, seizures, fractures etc). List of all medication and supplements and reason for use. What are your goals and expectations from physiotherapy treatment? Please list anything else you feel would assist us in optimizing your experience at WASS and ensure your safety. 4
5 Consent to the Release of Medical Information I,, give Whyte Ave Sport and Spine my informed consent to release/obtain information from the following individuals with respect to my care by report, letter, phone, fax, or direct communication: 1. Medical Professional(s): to disclose medical information to and obtain medical information from my physician, specialists, or other treating therapists for the purpose(s) of assessing or providing treatment services (Doctor Name): Yes No Initials Yes No Initials Yes No Initials 2. Employer or representative: to discuss return to work information with employer or their representative (as discussed with physiotherapist) (If applicable) Yes No Initials 3. Lawyer: to disclose medical information to my lawyer (If applicable) Yes No Initials 5. Other Yes No Initials I understand that my consent may be amended or revoked in whole or in part at any time by providing written notice to the Clinic, Whyte Ave Sport and Spine. Client Name Signature Date FOR OFFICE USE ONLY: I am responsible for ensuring form is completed in full/witness signing & entering above information into the computer. Name Date Signature Freedom of Information and protection of privacy: All information provided to Whyte Ave Sport and Spine is collected under the Freedom of Information and Privacy Act in the Province of Alberta. This information is used to support your care at WASS. Your personal information will remain confidential. Thank you for your assistance. 5
6 Assessment Consent Physiotherapy treatment techniques may include, but are not limited to: manual techniques including spinal manipulation, electrotherapeutic modalities and exercise as well as other techniques such as acupuncture and intramuscular stimulation (IMS). A number of these may be recommended during your program. As your participation in all aspects of your program is imperative to its success, it is the policy of Whyte Ave Sport and Spine to ensure the benefits, side effects and potential complications of each chosen modality are explained to you by your therapist before use. Throughout your program, if you have any questions or concerns about any recommended treatment you must inform your therapist immediately so they can explain the treatment rationale and/or modify your program appropriately. If at any time you choose not to participate in the program or any portion of it, you must inform your physiotherapist immediately. Therapist: Name: Date: I have provided my diagnosis and treatment I have reviewed risks, side effects and contraindications with proposed treatment Patient: Name: Date: I consent to receiving treatment and understand that I may remove my consent at any time Acupuncture and Intramuscular Stimulation As part of your treatment at Whyte Ave. Sport and Spine we may recommend Acupuncture or Intramuscular Stimulation (IMS). This is a form of therapy involving the use of acupuncture needles inserted into acupuncture points or muscles. Acupuncture is used to stimulate the release of Qi which helps reduce pain and inflammation. IMS is used to release shortened and tightening muscles and alleviate pain and restore function. Acupuncture and IMS are a valuable treatment for chronic pain. Like any medical procedure, there are possible complications. While these complications are rare in occurrence, there is a risk and must be considered prior to giving consent to the procedure. Side effects can include: temporary aggravation of symptoms, nausea, fatigue, fainting, pain, infection, broken or forgotten needles. Although very rare, there is a small chance of lung puncture. Manual therapy and/or Manipulations As part of your treatment, various manual therapy techniques will be utilized. Manipulations are high velocity techniques which may create and audible pop or click. When performed safely and effectively, these techniques can restore normal range of motion of a joint, decrease muscle spasm, and pain. Side effects may include: temporary aggravation of pain and symptoms, mild swelling Heat, Electrical Modalities and Ultrasound Various physiotherapy modalities may be utilized as part of your treatment such as TENS and interferential therapy (IFC). These modalities utilize mild electrical stimulation to decrease pain and inflammation. If you have altered skin sensation, skin allergies or sensitivity, open wounds or ulcers, please inform your therapist prior to use. 6
7 Consent to Communication Via As per the Privacy Information Act, your consent is necessary to communicate with you via . If you consent to communication via , please complete this consent form and return it to us in person, by or by fax ( ). We will file this consent form in your chart. If you do not wish to consent to communication via , please be advised we can no longer notify you of appointments, send receipts, updates, or clinic newsletters electronically and all further communication will need to be done in person or via telephone. Thank you. I, hereby consent to communication with Whyte ave. Sport and Spine and Physiomira (Mira Jindani, physiotherapist) at my address: address: (or provided in chart). As well, I am the account holder and if other people have access to this account I give them consent to receive the information sent to this account. Signed Date Freedom of Information and protection of privacy: All information provided to Whyte Ave Sport and Spine is collected under the Freedom of Information and Privacy Act in the Province of Alberta. This information is used to support your care at WASS. Your personal information will remain confidential. Thank you for your assistance. 7
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CAMARILLO AQUATICS AND REHABILITATION SERVICES Last Name First M.I. Address Apt.# City State Zip Code Phone # SS# Date of Birth Sex M F Driver s License # Marital Status: S M D W Spouse s Name How did
A photocopy of this document shall be considered as effective and valid as the original.
p In order for us to obtain a complete medical history, it is important for you to fill out this form in its entirety. Every item needs to be filled out. This information will be entered into our Electronic
Made to Move Physical Therapy, Inc. 615 N Nash St., Ste # 306 El Segundo, CA 90245 310.535.0008
Name Last First MI Date Current/Permanent address City State Zip Phone H W Cell Email Address: Marital Status Single Married Other Date of Birth: Age: Gender Male Female Spouses DOB: Employer Occupation
Home Phone Work Cell Email
Dr. Jerrid Goebel Licensed Acupuncturist 824 1 st Street Dr. Stuart Johnson Sturgis, South Dakota, 57785 Dr. Al Gunderson Telephone (605) 347-4003 Todays date: Patient s Name Date of Birth age Address
New England Pain Management Consultants At New England Baptist Hospital
New England Pain Management Consultants At New England Baptist Hospital Pain Management Center Health Assessment Dear New Pain Management Patient, Welcome to the New England Pain Management Consultants
Grey Physical Therapy and Sports Medicine Center
Grey Physical Therapy and Sports Medicine Center 101 Phoenix Ave, 2D Body Made Better by Grey A Tradition of Caring Since 1984 Enfield, CT 06082 Ph (860) 741-2541 F (860) 745-5264 Patient Information First
REHAB XCEL, LLC. NEW PATIENT INFORMATION
REHAB XCEL, LLC. NEW PATIENT INFORMATION DATE: NAME: LAST: FIRST: MID: MAIL ADDRESS: HOME PHONE: CELL PHONE: WORK PHONE: DATE OF BIRTH: SS# SEX: M OR F EMERGENCY CONTACT: PHONE: MARITAL STATUS: M OR S
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
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
Thank you for making an appointment with our office. We look forward to serving your visual needs.
Dear New Patient, Thank you for making an appointment with our office. We look forward to serving your visual needs. Enclosed you will find our New Patient Questionnaires. Please complete these and fax
Health History Form: Beverly Hosford, Muscle Activation Techniques Specialist
Health History Form: Beverly Hosford, Muscle Activation Techniques Specialist Name: Phone: Address: E-mail: Birthdate: Age: EMERGENCY CONTACT Name: Phone: Are you seeing any medical practitioners such
How To Get A Physical Therapy At West Point Physical Therapy Center
Palmdale (Main) 1115 West Ave. M-14 Palmdale, CA 93551 (661)265-0060 To our workers compensation patients: Cathedral City 68-845 Perez Rd., Ste. H6-H7 Cathedral City, Ca 92234 (760)328-0292 California
1 Central 601 West Second Street, Bloomington, IN 47402 t 812.353.9484 800.934.6074
Locations 1 Central 601 West Second Street, Bloomington, IN 47402 t 812.353.9484 800.934.6074 2 East 328 S. Woodcrest Drive, Bloomington, IN 47401 t 812.353.3278 866.353.3278 3 West 2499 W. Cota Drive,
Next Level Physical Therapy PC Patient Information
Next Level Physical Therapy PC Patient Information First Name M.I. Last Name Date of Birth SS# (if minor, leave blank) Student? F/T P/T NO Street Address Billing Address (if different) City State Zip Home
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
Patient Information: In Case of Emergency: Physician: Insurance:
For office use only: Start of Care: ICD-9 Codes: Patient Information: Name: Address: City: State: IL Zip: Patient of Birth: Policy Holders of Birth: of Injury or Onset of Symptoms: Home Phone: Work Phone:
Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340
Medical Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning our professional
Briefly describe the reason for your visit today (diagnosis, body part, or physical complaint):
Patient Registration Form Today s Date / / Last Name First Middle Date of Birth / / Age: Gender: M F Social Status: Single Married Live with domestic partner Live alone SSN: Contact Information: (please
PATIENT INFORMATION. Age: Street address: Email: Primary Phone no.: City: State: ZIP Code: P.O. box: Occupation: Employer: Employer phone no.
(Please Print) Today s date: PATIENT INFORMATION Patient s last name: First: Middle: Birth date: Age: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Sex: M F Street address: