Address: 8898 Clairemont Mesa Blvd Suite J, San Diego, CA Phone: Name:
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1 Address: 8898 Clairemont Mesa Blvd Suite J, San Diego, CA Phone: Name: Date of birth: Website: Age: Occupation: What is your primary concern? Pain location: Have you had surgery for this injury? No Yes Type of surgery/dates: History of falls in last year: No Yes Hospitalization in last 3 months? No Yes Medical History: Fracture or Suspected Fracture Rheumatoid Arthritis Alzheimer s High Blood Pressure Traumatic Brain Injury Cardiovascular Disease History of Cancer Allergies: Cauda Equina Syndrome Huntington s Unexplained Weight Loss CVA / Stroke Immunosuppression Pacemaker Current Infection Lupus Pregnant Diabetes Mellitus Type 1 Diabetes Mellitus Type 2 Seizures Muscle Dystrophy Osteoarthritis Blood Clots HIV/AIDS Hepatitis B/C Other: Diagnostics: X-Ray MRI CT Scan Diagnostic Ultrasound Results of Imaging: Medications: See attached Where is your problem? Indicate on the body chart. Nature of pain/symptoms (check all that apply): sharp aching constant dull periodic throbbing occasional other Are your symptoms: Improving Getting Worse Staying the Same What activities make your pain worse? What activities make your pain better? Have you ever had treatment before for these symptoms? No Yes If yes, list treatments: Overall activity level: Sedentary Light Moderate Heavy
2 Neck Disability Index Office Use Only This questionnaire has been designed to give us information as to how your neck pain has affected your ability to manage in everyday life. Please answer every section and mark in each section only the one box that applies to you. We realise you may consider that two or more statements in any one section relate to you, but please just mark the box that most closely describes your problem. I cannot lift or carry anything Section 1: Pain Intensity I have no pain at the moment The pain is very mild at the moment The pain is moderate at the moment The pain is fairly severe at the moment The pain is very severe at the moment The pain is the worst imaginable at the moment Section 2: Personal Care (Washing, Dressing, etc.) I can look after myself normally without causing extra pain I can look after myself normally but it causes extra pain It is painful to look after myself and I am slow and careful I need some help but can manage most of my personal care I need help every day in most aspects of self care I do not get dressed, I wash with difficulty and stay in bed Section 3: Lifting I can lift heavy weights without extra pain I can lift heavy weights but it gives extra pain Pain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently placed, for example on a table Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned I can only lift very light weights Section 4: Reading I can read as much as I want to with no pain in my neck I can read as much as I want to with slight pain in my neck I can read as much as I want with moderate pain in my neck I can t read as much as I want because of moderate pain in my neck I can hardly read at all because of severe pain in my neck I cannot read at all Section 5: Headaches I have no headaches at all I have slight headaches, which come infrequently I have moderate headaches, which come infrequently I have moderate headaches, which come frequently I have severe headaches, which come frequently I have headaches almost all the time Section 6: Concentration Name Date 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
3 Section 7: Work 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 I can t do any work at all Section 8: Driving I can drive my car without any neck pain I can drive my car as long as I want with slight pain in my neck I can drive my car as long as I want with moderate pain in my neck I can t drive my car as long as I want because of moderate pain in my neck I can hardly drive at all because of severe pain in my neck I can t drive my car at all Section 9: Sleeping I have no trouble sleeping My sleep is slightly 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) Section 10: Recreation I am able to engage in all my recreation activities with no neck pain at all I am able to engage in all my recreation activities, with some pain in my neck I am able to engage in most, but not all of my usual recreation activities because of pain in my neck I am able to engage in a few of my usual recreation activities because of pain in my neck I can hardly do any recreation activities because of pain in my neck I can t do any recreation activities at all Score: /50 Transform to percentage score x 100 = %points Scoring: For each section the total possible score is 5: if the first statement is marked the section score = 0, if the last statement is marked it = 5. If all ten sections are completed the score is calculated as follows: Example:16 (total scored) 50 (total possible score) x 100 = 32% If one section is missed or not applicable the score is calculated: 16 (total scored) 45 (total possible score) x 100 = 35.5% Minimum Detectable Change (90% confidence): 5 points or 10 %points NDI developed by: Vernon, H. & Mior, S. (1991). The Neck Disability Index: A study of reliability and validity. Journal of Manipulative and Physiological Therapeutics. 14,
4 Informed Consent for Physical Therapy Physical therapy involves the use of many different types of physical evaluation and treatment. At Evercore, we use a variety of procedures and modalities to improve your function. As with all forms of medical treatment, there are benefits and risks involved with physical therapy. Since the physical response to a specific treatment can vary widely from person to person, it is not always possible to accurately predict your response to a certain therapy modality or procedure. We are not able to guarantee precisely what your reaction to a particular treatment might be, nor can we guarantee that our treatment will help the condition you are seeking treatment for. There is also a risk that your treatment may cause pain or injury, or may aggravate previously existing conditions. You have the right to ask your physical therapist what type of treatment he or she is planning based on your history, diagnosis, symptoms and testing results. You may also discuss with your therapist what the potential risks and benefits of a specific treatment might be. You have the right to decline any portion of your treatment at any time before or during your treatment session. Therapeutic exercises are an integral part of most physical therapy treatment plans. Exercise has inherent physical risks associated with it. If you have any questions regarding the type of exercise you are performing and any specific risks associated with your exercises, your therapist will be glad to answer them. I acknowledge that my treatment program has been explained by Evercore, and all of my questions have been answered to my satisfaction. I understand the risks associated with a program of Physical Therapy as outlined to me, and I wish to proceed. Client Name Client Signature Date Copyright Evercore, LLC. All Rights Reserved.
5 Cancellation Policy We understand there are times when situations arise that make it necessary for you to cancel your appointment. It is your responsibility to call us as soon as you know you will not make your appointment. This allows us to fill your spot with another client who wants that time slot. A cancellation fee of $35 will be charged if you cancel within 24-hours. Note: Please be on time for your session. If you are late, the session will still finish on time. These policies help the us provide quality care to our valued clients. If you have any questions or need clarification of any of the above policies, please do not hesitate to call us. Contact Info: Address: 8898 Clairemont Mesa Blvd Suite J, San Diego, CA Phone: marc@evercorelife.com CLIENT S SIGNATURE DATE
6 Expectations with Physical Therapy What can physical therapy do for me? Physical therapy will help you reduce pain, recover from your injuries, reduce your risk of injury and increase your strength. Physical therapy helps you get back to the things you love and feel more active We may use hands-on techniques, movements and exercises to correct the underlying factors contributing to your injury. You will learn how to manage your injuries and pain without surgery, injections or pain medications. How long is each session? Each session consists of 30-minutes of one-on-one training with Dr. Marc. You may be here for 45-minutes total to complete your mobility and movement therapy exercises What should I wear? Wear athletic clothes We have a shower you can use if you need to shower before you go back to work. What should I bring? Bring a water bottle if you want. We have purified water to refill your water bottle. Fill out the forms in this folder and bring the forms with you to your next session. Bring your smartphone if you want me to record you doing exercises on your phone. You can reference these videos for your home exercise program. Home exercise program You will receive exercises to perform at home. I will send you a PDF handout with pictures of your exercise program. We may use your smartphone to record you doing your exercises. Movement analysis We may do a video movement analysis using a smartphone. We will be analyzing your movements during functional activities like squats, lunges, reaching overhead, or other activities that are difficult for you.
7 Will I feel sore after our sessions? There is a difference between muscle soreness and pain. It is normal to feel muscle soreness. It is normal to have setbacks while recovering from an injury. We will assess your progress each session and make changes as needed to ensure you are improving. How long will it take for me to get better? Your ability to reduce or eliminate pain will be determined by several factors such as: length of time you have been dealing with the injury, severity of the injury, normal healing time of the injury, and your consistency with the home exercise program. Within 4-6 weeks, you should have significantly less pain and feel more active. How can I get better faster? Follow your exercise program and show up for each physical therapy session Allow time for your body to heal and do not rush the recovery process What is our contact information? Address: 8898 Clairemont Mesa Blvd Suite J, San Diego, CA Phone: marc@evercorelife.com Visit our website for helpful videos, articles and resources to recover from injuries and get stronger. Follow us on social media for daily exercise videos: Instagram: Evercorelife Facebook: Evercore YouTube Channel: Evercorelife If you have any additional questions or comments feel free to contact us. To your health, Dr. Marc Robinson, PT, DPT, Cert. MDT Physical Therapist/Co-founder of Evercore
Address: 8898 Clairemont Mesa Blvd Suite J, San Diego, CA Phone: Name:
Address: 8898 Clairemont Mesa Blvd Suite J, San Diego, CA 92123 Phone: 1-800-760-5469 Name: Email: marc@evercorelife.com Date of birth: Website: www.evercorelife.com Age: Occupation: What is your primary
Address: 8898 Clairemont Mesa Blvd Suite J, San Diego, CA Phone: Name:
Address: 8898 Clairemont Mesa Blvd Suite J, San Diego, CA 92123 Phone: 1-800-760-5469 Name: Email: marc@evercorelife.com Date of birth: Website: www.evercorelife.com Age: Occupation: What is your primary
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Peterson Physical Therapy
Peterson Physical Therapy Registration Form Last Name: First Name: Date: Name of parent/guardian (if patient is a minor) Mailing Address: City/State/Zip: Date of Birth: Home Phone: Email: Cell Phone: Cell
PERSONAL INFORMATION. Date of Birth Age (Last) (First) (M.I.) Address City/State Zip. Phone # Home Work Cell
*If the reason for your visit is due to a worker s compensation injury or an automobile accident, please inform the front desk immediately. PERSONAL INFORMATION of Birth Age (Last) (First) (M.I.) Address
Initial Visit Forms. Life in Motion Chiropractic & Wellness 6139 Route 96 -Suite 1 Farmington, NY (585)
Initial Visit Forms 6139 Route 96 -Suite 1 Patient Name: Patient Intake Form Name: Date: Address: City: State: Zip: Home #: ( ) Cell #: ( ) Work #: ( ) E-mail: Preferred method of contact: Date of Birth:
Patient Health History
Today s Date: Patient Information First Name: M.I. Last Name: Mailing Address: City: State: Zip: Telephone:(home) (work) (cell) Email address: Secondary email: Occupation: Employer: Preferred language:
Shepherd Integrative Physical Therapy
Shepherd Integrative Physical Therapy Appointment Information and Forms Below is important information you will need regarding your upcoming appointment. Please call or email if you have any questions
Patient Intake Form. I prefer to receive calls at (circle) Home/Work/Cell I am (circle) Under Age18/Single/Married/Divorced/Widowed/Separated
Patient Information Full Name: First MI Last Patient Intake Form Date: Address: City: State: Zip: Age: Birth Date: Female: Male: Social Security Number: Email Address: Home Phone: Work Phone: Cell/Other:
Patient Health History
Patient Health History Today s Date / / Signature of Patient Patient Title: (check one) Mr. Mrs. Ms. Miss Dr. Prof. Rev. First Name Middle Name Last Name Nick Name Suffix Address 1 Address 2 City State
Salisbury Chiropractic, PC
Salisbury Chiropractic, PC Patient Data Date First Name Middle Initial Last Name Address Line 1 City State Zip Code Home Phone ( ) - Cell Phone ( ) - Work Phone ( ) - Email Date of Birth / / Age: Sex:
* CC* PATIENT QUESTIONNAIRE
Pain Center of Michigan *0290341CC* PATIENT QUESTIONNAIRE Patient Name Birthdate Age Home Address City State Zip Home Phone Alternate Phone Referring Physician Primary Care Physician MEDICAL HISTORY Please
Is today's problem caused by: Auto Accident Workman's Compensation Slip and Fall Other. Address City/State/Zip Phone # (home) (cell)
Patient s Name: Date: What is the reason for your visit today? Is today's problem caused by: Auto Accident Workman's Compensation Slip and Fall Other Personal Information Address City/State/Zip Phone #
NEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Name: LAST FIRST MIDDLE Date of Birth: Sex: Marital Status: SS Number: Address: City: State: Zip Phone: Home Cell Work Email: Communication Preference: Patient Portal Phone
CHIROPRACTIC INTAKE FORM
3885 Duke of York Blvd., Suite C211, Mississauga, ON L5B0E4 T: (905)276-6800 F: (905)276-6802 www.naturawellnessclinic.com CHIROPRACTIC INTAKE FORM DATE: PATIENT INFORMATION Name Sex: M/F Age Date of Birth
PATIENT INTAKE FORM PATIENT S PREFERED NAME DATE COMPLETED
PATIENT INTAKE FORM WELCOME and THANK YOU for seeking out care at our office. We are a very unique team specializing in research based spinal and postural rehabilitation that helps our patients recover
Pain Interventions 30 Hagen Drive, Suite Culver Rd. Suite 2 Rochester, NY Rochester, NY (Voice) (Fax)
Pain Interventions 30 Hagen Drive, Suite 230 2619 Culver Rd. Suite 2 Rochester, NY 14625 Rochester, NY 14609 (Voice) 585.899.3450 (Fax) 585.899.3454 We would like to welcome you to our office. For the
Home Address. City Postal Code Home Telephone # Business Telephone # Address. Emergency Contact Name, Address, Phone#
Date Name / / last first middle initial Personal Health # - Male Female Home Address City Postal Code Home Telephone # Business Telephone # Cell # E-Mail Address Best way to contact you: Home # Work #
MEDICAL HISTORY FORM
MEDICAL HISTORY FORM Patient Name: Date of Birth: Date: Email: Address: Emergency Contact (name, relationship to patient, & phone): Height: Weight: Right/Left Hand Dominant: [ ] Male [ ] Female What area
Saleeby Chiropractic Centre, P.A.
Saleeby Chiropractic Centre, P.A. Stephen M. Saleeby, D.C. Wayne J. Prickett, D.C. Today s Date: / / Chiropractic Intake Z: Name: DOB: / / Age: First MI Last Preferred Name: Address City State Zip Code
NAME: DATE: SPINE CENTER NEW PATIENT QUESTIONNAIRE
Please complete and give to the receptionist when you arrive at the office for your appointment. NAME: DATE: SPINE CENTER NEW PATIENT QUESTIONNAIRE Page 1 of 6 Primary Care Physician s Name Primary Care
Chima Ohaegbulam, MD Spine Surgery, Neurosurgery
Chima Ohaegbulam, MD Spine Surgery, Neurosurgery Converse 4 617 754 6025 125 Parker Hill Avenue FAX 617 754 6026 Boston, MA 02120 spineboston.com Dear You have been scheduled for an initial evaluation
Pro Active Physical Therapy & Sports Medicine
Pro Active Physical Therapy & Sports Medicine Consent and Statement of Financial Responsibility 1. CONSENT FOR TREATMENT: I consent to and authorize my physical therapist, occupational therapist and other
Welcome to Lone Lake Physical Therapy!
Welcome to Lone Lake Physical Therapy! **Please arrive 5-10 min prior to your appointment time for your first session. Your appointment will last approximately 55-60 min What you should know before your
Thank you for choosing Therapy Works to assist you with your current condition.
Therapy Works Welcome Packet Thank you for choosing Therapy Works to assist you with your current condition. Please fill out the enclosed paperwork and bring back with you to your appointment. Important