Please arrive 15 minutes prior to your appointment to allow us time to prepare your chart and to sign your insurance financial agreement.

Transcription

1 Thank you for scheduling an appointment with us! Please print pages 2-7 & bring them to your first appointment. Please arrive 15 minutes prior to your appointment to allow us time to prepare your chart and to sign your insurance financial agreement. Completed paperwork (please use black ink) Insurance cards Drivers license or other form of picture ID Prescription from the referring physician for physical therapy, unless it has already been sent to our office Your personal calendar for appointment scheduling Please wear comfortable clothes Feel free to contact us with any questions or concerns; we look forward to helping you on the road to recovery. Sincerely, South Austin Therapy Group Staff 1

2 CANCELLATION/NO SHOW & ATTENDANCE POLICY We require that you notify our office no later than 24 hours before your scheduled appointment time if you need to cancel or re-schedule your appointment. Please contact the office and leave a voic if you are unable to speak with anyone. Please be respectful of your appointment time and realize your attendance is important to your progression and recovery. Please respect that we are a small business and a late cancel has a significant financial impact. We often operate on a waitlist, so proper notification allows another patient to be treated. We will send a courtesy appointment reminder via text or 24 hours before your next appointment, if requested at your initial appointment. Appointment reminders are not guaranteed and we recommend you keep your appointments on your personal calendar. If you need to change an appointment, please call the office BEFORE you receive your reminder. If you cancel your appointment with less than 24 hour notice or fail to show up to your appointment, you will be charged a $40 late cancellation fee. If you arrive 15 minutes late to your appointment start time, you will be charged a $25 late fee. Arrival later than 20 minutes can result in your therapist cancelling your appointment, and you will owe the $40 cancellation fee. If you have three (3) missed appointments (late cancels or re-scheduled appointments), no shows, or late arrivals your therapist has the right to discharge you from physical therapy. Patient Signature: Date: 2

3 Patient Demographic Information Today s Date: First Name: Middle Name: Last Name: Date of Birth: / / Age: Marital Status: Divorced Single Married Sex: Female Male Widowed Address: City: State: Home Phone: Zip Code: Cell Phone: Work Phone: Preferred number: Home Cell Work address (for appt reminder) : Employer: Occupation: Emergency Contact Name: Emergency Contact Relationship: How did you find our clinic? Referring MD insurance Phone : family/friend website Appointment Reminders: We can send you an appointment reminder 1 day before your appointment. Please check preferred method of reminder. Make sure the information is provided above. : (we will only use your address for appointment reminders) : text message : I do not want a reminder PLEASE SEE CANCELLATION/NO SHOW POLICY. WE REQUIRE 24 HOUR NOTICE TO AVOID CHARGES 3

4 Patient Information Patient Name: DOB: Please describe your current condition: How long have you had this problem? weeks months years Was your first episode of the problem related to a specific incident? Yes r No If Yes, please describe: Is your condition: Worsening Improving No change If pain is present, rate your pain on scale of 1 to is severe pain. Current /10 Worst /10 Describe your pain (i.e constant, intermittent, burning, aching): Describe prior treatment/exercises: Activities/events that create or aggravate your symptoms: Sitting greater than minutes With laughing or yelling Standing greater than minutes With cough, sneeze, or straining Walking greater than minutes With lifting or bending Changing positions (i.e. sit to stand) With cold weather Light activity (light housework) With triggers running water, key in door Vigorous activity/exercise (run, weight lift, With nervousness or anxiety jump) No activity affects the problem Other, please list: What relieves your symptoms? Has your lifestyle, quality of life been altered/changed because of this problem? Please specify. Social Activities (excluding physical activities): Diet/Fluid Intake: Physical activity: Work: Other: Please rate the severity of this problem, with 10 being the worst: /10 What are your treatment goals/concerns? Since the onset of your current symptoms, have you had: Fever/chills Dizziness or fainting Unexplained muscle weakness Unexplained weight change Change in bowel or bladder functions Night pain or sweats Malaise (unexplained tiredness) Numbness or tingling Other: 4

5 Health History: Patient Name: Date of last physical exam: General Health: DOB: Tests Performed: Excellent Good Average Fair Poor Mental Health: Current level of stress High Medium Low Height: Weight: Current Psych therapy? yes no Activity/Exercise: None 1-2 days a week 3-4 days a week 5 days a week Describe: List current medications & dosage. Please feel free to attach separate list or request to make a copy. Have you ever had any of the following conditions or diagnosis? (Check all that apply): Cancer Hypo/Hyperthyroid Irritable bowel syndrome Diabetes Arthritic conditions Childhood bladder problems High blood pressure Rheumatoid Arthritis Pelvic pain Heart problems Hepatitis Interstitial cystitis Stroke Raynaud s (cold hands and Sjogren's syndrome feet) Emphysema/chronic Sexually transmitted disease bronchitis Anorexia/bulimia Physical or sexual abuse Asthma HIV/AIDS Epilepsy/seizures Depression TMJ/neck pain Anemia Anxiety Hearing loss/problems Osteoporosis Headaches Vision/eye problems Kidney disease Low back pain Latex sensitivity Alcoholism/Drug problem Sacroiliac/tailbone pain Fibromyalgia Smoking history Chronic Fatigue Syndrome Allergies (List below) : Other (describe): Surgical/Procedure history: Back/spine Bones/joints OB/GYN History (females only): Childbirth vaginal deliveries # Difficult childbirth # Vaginal dryness Prolapse, organ falling out Episiotomy # Bladder/prostate Female organs Brain Abdominal organs Menopause when? Painful periods C- section# Painful vaginal penetration Pelvic pain Male History Only: Prostate disorders Erectile dysfunction Shy bladder Painful ejaculation Pelvic pain Other: 5

6 Pelvic Symptom Questionnaire Patient Name: Bladder & Bowel Habits/Problems Trouble initiating urine stream Blood in urine Urine intermittent/slow stream Painful urination Trouble emptying bladder Trouble feeling bladder urge/fullness Difficulty stopping the urine stream Current laxative use Trouble emptying bladder completely Trouble feeling bowel urge/fullness Straining or pushing to empty bladder Constipation/straining Dribbling after urination Trouble holding back gas/feces Constant urine leakage Recurrent bladder infections Other: Frequency of urination: Awake hours: times per day Sleep hours: times per day When you have a normal urge to urinate, how long can you delay before you need to go to the toilet? Seconds Minutes Hours Not at all The usual amount of urine passed is: Small Medium Large Frequency of bowel movements: times per day times per week Other When you have a normal urge for a bowel movement, how long can you delay? Seconds Minutes Hours Not at all If constipation is present, describe management techniques: Average fluid intake: glasses per day (1 glass = 8 oz, 1 cup) How many are caffeinated? per day Rate a feeling of organ falling out /prolapse or pelvic heaviness/pressure None present times per month If yes, are these times related to your period? yes no With standing If yes, please specify: minutes hours With exertion or straining Other: Bladder leakage - Number of episodes times per day times per week times per month Only with physical exertion/cough On average, how much urine do you leak? Just a few drops Wets underwear Wets outwear Wets the floor Bowel leakage Number of episodes times per day times per week times per month Only with exertion/strong urge How much stool do you lose? Stool staining Small amount in underwear Complete emptying What form of protection do you wear? None Minimal (tissue paper, panty shield) Moderate (absorbent pad, maxipad) Maximum (special product, diaper) Other: How many pad/protective changes are required in 24 hours? 6

7 PELVIC FLOOR CONSENT FOR EVALUATION AND TREATMENT I acknowledge and understand that I have been referred for evaluation and treatment of pelvic floor dysfunction. Pelvic floor dysfunctions include, but are not limited to, urinary or fecal incontinence; difficulty with bowel, bladder, or sexual functions; painful scars after childbirth or surgery; persistent sacroiliac or low back pain; or pelvic pain conditions. I understand that to evaluate my condition it may be necessary, initially and periodically, to have my therapist perform an internal pelvic floor muscle examination. This examination is performed by observing and/or palpating the perineal region including the vagina and/or rectum. This evaluation will assess skin condition, reflexes, muscle tone, length, strength and endurance, scar mobility, and function of the pelvic floor region. Such evaluation may include vaginal or rectal sensors for muscle biofeedback. Treatment may include, but not be limited to, the following: observation, palpation, use of vaginal weights, vaginal or rectal sensors for biofeedback and/or electrical stimulation, ultrasound, heat, cold, stretching and strengthening exercises, soft tissue and/or joint mobilization, and educational instruction. I understand that in order for therapy to be effective: I must come as scheduled unless there are unusual circumstances that prevent me from attending therapy. I agree to cooperate with and carry out the home program assigned to me. If I have difficulty with any part of my treatment program, I will discuss it with my therapist. The purpose, risks, and benefits of this evaluation have been explained to me. I understand that I can terminate the procedure at any time. I understand that I am responsible for immediately telling the examiner if I am having any discomfort or unusual symptoms during the evaluation. I hereby authorize payment of all health benefits to South Austin Therapy Group and allow assignee to release all information necessary to secure payment. I agree that a photocopy of this authorization shall be considered as effective and valid as original. I understand that I am legally responsible for all charges incurred whether or not they are paid for by said insurance and that any unpaid balance shall be due in full immediately if insurance proceeds are paid to me. I hereby authorized the release of medical records, inclusive or all results of testing and other pertinent information acquired Patient/Legal Guardian Signature Date Therapist Signature Date 7