Welcome to our practice! Please help us serve you better by taking a few minutes to provide the following information.

Transcription

1 New Patient Intake Form Welcome to our practice! Please help us serve you better by taking a few minutes to provide the following information. Name: Last Name First Name Today s date: Address: City / State / ZIP: Phone # MOBILE HOME WORK DOB: Age: Marital status: M S W D Occupation: Employer: Emergency Contact Name: Phone: Primary Care Physician Name: Date of next visit Specialist Physician Name: Date of next visit Height / Weight lbs How did you hear about our practice? Who can we thank for referring you to our practice? What other types of treatment have you had for this problem? Massage Bodywork Physical Therapy Myofascial Release Chiropractic Surgery Other Medical Treatment: (Please Describe)

2 New Patient Intake Form The following is very important in our evaluation process. Please fill out these forms as specifically as possible to provide us with a clear picture of your present pain and functional status. What is the primary issue/problem that brings you in today? Secondary concern/problem? Please shade in areas where you have pain, discomfort, or tension. As a result, I am now having difficulty with: Are you currently experiencing pain as a result of these symptoms? If yes, what is it like? When did your symptom(s) begin? (Date): At its worst Please rate your pain in the last hours Using the 0-10 scale where 0 is no pain and 10 is the worst possible pain. At its best At present Night (sleeping) At what time of day are your symptoms the worst? At what time of day are your symptoms the best? What activities increase your pain? What activities decrease your pain?

3 New Patient Intake Form Page 3 Check the box if you have had any of the following medical conditions? Diabetes Lung disease Weight change Varicose veins Neurological problems Pregnancy Rheumatic fever Osteoporosis Migraine headaches Epilepsy / seizures Stroke Blackouts Heart Murmur Malignancy Arthritis Broken bones (fracture Metal implants High blood pressure Circulatory problems Liver disease Heart disease / pacemaker Kidney disease Chest Pain Hot/Cold Intolerances Allergies Asthma Dizziness Bladder Infection Cancer Fatigue Kidney Disease Swallowing Difficulty Vascular Condition Lyme Disease Difficulty breathing Concussion/Head injury Gynecological issues Thyroid Pacemaker Gastrointestinal List past medical history and dates of occurrence. Include surgeries, accidents and other traumas. Diagnostic Tests Test Date Results X-ray MRI CAT SCAN Other

4 New Patient Intake Form Page 4 List ALL medications which you are currently taking, the condition for which you are using them, the dose, and their effectiveness. (Include supplements, herbal and homeopathic remedies). Medication For treatment of Dose / Amount per day Effectiveness Do you smoke? Yes No If Yes How much? When did you quit? If not, Would you like to quit? Is there a chance you may be pregnant at this time? Yes No Do you engage in regular exercise? Yes No What type and how often? Are you able to exercise now? Yes No Do you have discomfort, shortness of breath, or pain with exercise? Yes No Please Describe: In general, your lifestyle is: Active Average Inactive If sleep is a problem, answer these questions: Do you have trouble falling asleep? Yes No Do you find it difficult to change positions in bed? Is your sleep restful? Yes No How many times do you wake in the night? Do you find it difficult to lie down? Yes No How long before you fall back to sleep?

5 New Patient Intake Form Page 5 List all the Tasks / Activities that you have difficulty performing and your tolerance (minutes/hours). If you are no longer able to perform an activity, your tolerance would be 0. Task / Activity Tolerance (minutes/hours) I walk for I stand for I sit for minutes before needing to rest minutes before needing to sit minutes before needing to change positions/get up Do you have trouble getting up from a chair? Yes No Do you have trouble putting on your shoes and socks? Yes No Do you have difficulty climbing stairs? Yes No Patient Goals Please list the activities that you would like to be able to do as a result of therapy. Task / Activity Duration / How Often By When Other Goals?

6 Informed Consent Page 6 Informed Consent The term informed consent means that the potential risks, benefits, and alternatives of therapy evaluation and treatment have been explained to you. The therapist provides a wide range of services and I understand that I will receive information at the initial visit concerning the evaluation, treatment and options available for my condition. Payment We are dedicated to providing the best possible care for you, and we want you to completely understand our financial policies. Payment is due at the time of service, we accept Visa, Mastercard, American Express, cash and checks. Insurance We are out of network with all insurance companies except Medicare. As a courtesy we will prepare and send the claim for you and send out all necessary forms. The most amount you will be responsible for is $ for the initial visit and $ for follow up session. I understand that my insurance forms will be submitted electronically/mailed from SoulCare PT so that I may get reimbursed. It is my responsibility to follow up on my reimbursements with my insurance company. Not all insurance plans cover all services. In the event your insurance plan determines a service not to be covered, you will be responsible for those charges. Please be aware that some insurance companies have a maximum number of visits that you are allowed; some companies also require prior authorizations. It is the patient s responsibility to know their physical therapy benefits, check with their insurer if the prior authorization is required and to follow up with our office if it was obtained & visits were approved. Privacy I understand that SoulCare Physical Therapy will maintain my privacy to the highest standards and may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. Photographs taken during initial evaluation, progress evaluation and discharge summary will be used for postural comparison purposes and as educational tools. By signing below I consent to the use of these photographs in a professional manner. I do hereby agree and give my consent for SoulCare Physical Therapy to furnish care and treatment that is considered necessary and proper in the diagnosing or treating of my physical condition. I understand that I retain the right to revoke this consent by notifying the practice in writing at any time. I hereby certify that all the above information is true to the best of my knowledge. I have read and understood SoulCare Physical Therapy s financial policy and agree to be bound by its terms. I also understand that such terms may be amended by the practice from time to time. Patient/Parent/Guardian Signature: Date: