PATIENT REGISTRATION FORM

Transcription

1 Date: Patient Information: (Please Print) Patient s Name: PATIENT REGISTRATION FORM First Middle Initial Last Address: Home Phone: ( ) Gender: M F Age: Date of Birth: Marital Status: Single Married Domestic Partnership Widowed Divorced Separated Employer: (If Applicable) Occupation: Business Phone: ( ) Cell Phone: ( ) Employer s Address: Address: Add me to the 360 Balance Mailing List: Yes No In case of emergency please contact: Relation: Phone: ( ) How did you hear about our clinic? Insurance Information: Insurance Primary Cardholder: (If Person Other Than Yourself) D.O.B.: Social Security #: (If Primary Cardholder Is Person Other Than Yourself) Primary Cardholder Employer: (If Applicable) If Patient is a Minor: Bus. Phone: Legal Guardian s Name: Soc. Sec. #: First Last MI Address: Home Phone: Business Phone: Birthdate: Reason for Consultation: Reason for Consultation: Are you here regarding a work-related injury? Yes No Referring Doctor: Phone: Date of Last Visit with Referring Doctor: Family Physician: Phone: Medicare Patients Only: Have you received physical or occupational therapy from another provider during this calendar year? Yes No Are you currently receiving any home health services (ex. PT, OT, Speech, Nursing, etc.)? Yes No

2 HEALTH HISTORY QUESTIONNARE All of the information that you provide in this questionnaire is strictly confidential and will become part of your medical record. Social/Health Habits: Do you smoke tobacco? No Amount: Do you drink alcohol? No Amount: Do you recreational drugs? No Amount: Do you exercise? No Yes If yes, how many days per week? minutes/day? Describe exercise or activity: Employment/Work: Work Status: Unemployed Working Full-time Working light duty Student Homemaker Working Part-time Disabled Retired Occupation: General Health Status: Please rate your health: Excellent Good Fair Poor Don t Know Major life Changes (past year): None Death in Family New Job Divorce Move Family History: Please check if anyone in your family has or had any of the following: Heart disease High blood pressure Cancer Psychological problems Pulmonary/Lung disease Diabetes Arthritis Stroke Osteoporosis Allergies Hearing Loss Vertigo Balance problems Other: Your Past Medical History: No history Diabetes Kidney Disease Parkinson s Disease AIDS Emphysema Liver Disease Prostate Disease Allergies Epilepsy/Seizures Low blood pressure Skin disorders Asthma Fibromyalgia Lung disorder Sleep disorders Arthritis Glaucoma Lyme s Disease Stroke Blood disorders Heart attack Macular Degeneration Thyroid disorders Broken bones Heart Disease Meniere s Disease Ulcers (stomach) Chronic Fatigue Syndrome Hepatitis Migraines Repeated infections Circulation problems Head Injury Muscular Dystrophy Reoccurring Vertigo Cancer High blood pressure Multiple Sclerosis Cystic Fibrosis High cholesterol Osteoporosis Depression Genetic Disease Pacemaker For women only: Pelvic Inflammatory Disease? No Yes Trouble with period? No Yes Complicated pregnancies? No Yes Currently pregnant? No Yes Endometriosis? No Yes Other: Increase in current symptoms with hormonal changes? No Yes

3 Surgical History: Please list any surgeries you have had and, if known, include dates: No surgeries to date 1. Date: 2. Date: 3. Date: 4. Date: Symptom Checklist: Within the last year, have you had any of the following (check all that apply): No symptoms Headaches Syncope (passing out) Bowel problems Hearing loss Tinnitus (noises in your ear) Chest pain Heart palpitations Tremors Cough (persistent) Joint pain or swelling Urinary problems Concentration problems Loss of appetite Vertigo Difficulty driving Loss of balance Vision problems Difficulty walking Motion sickness Weakness in arms/legs Difficulty sleeping Nausea/Vomiting Weight gain (unexplained) Dizziness Numbness in arms/legs Weight loss (unexplained) Excessive sweating Pain at night Dizziness with loud noises Fatigue Pressure in your ears Dizziness with physical exertion Foggy headedness Shortness of breath Other: Diagnostic Tests / Measures: Within the last year, have you had any of the following (check all that apply): No diagnostic testing Bronchoscopy Hearing tests Pulmonary Function Test Angiogram CT scan Mammogram Speech/Language evaluation Arthroscopy Ultrasound MRI Stool test Biopsy Echocardiogram Pap smear Stress test Blood test EEG EMG/Nerve conduction Urine test Bone scan EKG ENG X-Ray Other: Medications: Please check or list all medications or allergies: Non-Prescription: No medications Decongestants Motrin Advil/Alleve Excedrin Vitamins/minerals Antihistamine Herbal supplements Tylenol Aspirin Ibuprofen/Naproxen Other: Prescription: No medications See attached list Allergies: Drug allergies: No Yes, please list: Airborne pathogens: No Yes, please list: Are you receiving any treatment for above stated allergies? If yes, please describe:

4 Dizziness Handicap Inventory-Screening version (DHI-S) Instructions: The purpose of this scale is to identify difficulties that you may be experiencing because of your dizziness or unsteadiness. Please place a check in the appropriate column for yes, no, or sometimes for each question. Answer each question as it pertains to your dizziness or unsteadiness problem only. Y N S (4) (0) (2) E1. Because of your problem, do you feel depressed? P2. Does walking down a sidewalk increase your problem? E3. Because of your problem, is it difficult to concentrate? F4. Because of your problem, is it difficult for you to walk around your house in the dark? P5. Does bending over increase your problem? F6. Because of your problem, do you restrict your travel for business or recreation? F7. Does your problem interfere with your job or household responsibilities? E8. Because of your problem, are you afraid to leave your home without having someone with you? E9. Because of your problem, have you ever been Embarrassed in front of others? F10. Does your problem significantly restrict your participation in social activities such as going out to dinner, going to movies, dancing or to parties? Total Score:

5 Please Review and Sign Below Consent of Treatment, Authorization to Release Information, Notice of Privacy Practices, Billing Disclosures/Financial Responsibility and No Show Policy: Patient Name: Date: Acct #: I hereby authorize 360 Balance & Hearing through its appropriate personnel, to furnish medical care and treatment to me, or the above named patient, considered necessary and proper in diagnosing or treating my/his/her physical condition. I further authorize 360 Balance & Hearing to release to appropriate agencies, any information acquired in the course of my or the above named patient s examination and treatment necessary to secure payment for services provided. I acknowledge that the Notice of Privacy Practices is posted at the location in which I am receiving treatment and that I have read and understand the notice. I further acknowledge that I have the right to request a copy of the notice and one will be provided to me. At 360 Balance & Hearing, our mission is to value every individual and meet the healthcare needs of patients and their families that suffer from dizziness, balance and/or hearing disorders. The service you have elected to participate in implies a financial responsibility on your part. You are responsible for payment of any co-payment at the time of service and on receipt of a bill for any deductible/coinsurance as determined by your contract with your insurance carrier. You are responsible for any amount not covered by your insurer. It is also your responsibility to have knowledge of pre-certification/prior authorization requirements as stated in your insurance policy and to ensure pre-certification/ prior authorization is obtained from your insurance company prior to engaging in services with 360 Balance and Hearing. If your insurance carrier denies any part of your claim, or if you and your physician elect to continue therapy past your approved period, you will be responsible for your account balance in full. If collection for this invoice is placed in the hands of an attorney, attorney fees equal to 30% of the total invoice price shall be due and owing. If any legal action is required, it is agreed that the venue for such shall be in Travis County, Texas. I have read the above information regarding my financial responsibility to 360 Balance & Hearing for providing services to the above named patient or me. I certify that the information provided is, to the best of my knowledge, true and accurate. I authorize my insurer to pay any benefits directly to 360 Balance & Hearing. I agree to pay 360 Balance & Hearing the full and entire amount of all bills incurred by me or the above named patient, if applicable, any amount due after payment has been made by my insurance carrier. I hereby authorize 360 Balance & Hearing to furnish information to insurance carriers and doctors concerning my illness and treatments, by fax or mail. I hereby authorize 360 Balance & Hearing to disclose my health information that is directly related to my current treatment at 360 Balance & Hearing to the individual(s) listed below for purposes of their role in my treatment or payment for the health services that I have received. Such persons involved in your care may include: spouse, children, blood relatives, roommates, boyfriends/girlfriends, domestic partners, neighbors and colleagues. Name: Relationship: It is our policy to collect credit card information at the time of scheduling your appointment in the event of a late cancellation or no show. Your credit card information will be securely stored in your electronic medical record and you will only be charged a one-time fee depending on the service(s) scheduled and we take into consideration emergency situations. There is a $50 no-show/latecancellation fee for physical therapy appointments and hearing test with a $75 no-show/late-cancellation fee for audiology appointments. All appointments must be cancelled by 5 p.m. of the previous day (or by 3 p.m. on Friday for a Monday appointment), to avoid charges for a no-show or late-cancellation. After-hour messages regarding cancellations may be left at Insurance will not cover charges for no-show/late-cancellation or eligibility fees. I acknowledge that I have read and understand the No Show Policy. Signature: (relationship to patient: self - guardian - other: ) Date: