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 Shoulder Pain and Disability Index (SPADI) Shoulder Pain and Disability Index (SPADI) Please place a mark on the line that best represents your experience during the last week attributable to your shoulder problem. Pain scale How severe is your pain? Circle the number that best describes your pain where: 0 = no pain and 10 = the worst pain imaginable. At its worst? When lying on the involved side? Reaching for something on a high shelf? Touching the back of your neck? Pushing with the involved arm? Disability scale How much difficulty do you have? Circle the number that best describes your experience where: 0 = no difficulty and 10 = so difficult it requires help. Washing your hair? Washing your back? Putting on an undershirt or jumper? Putting on a shirt that buttons down the front? Putting on your pants? Placing an object on a high shelf? Carrying a heavy object of 10 pounds (4.5 kilograms) Removing something from your back pocket? Page 2
3 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.
4 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
5 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.
6 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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Baylor Physical Medicine and Rehabilitation NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny Dear Patient: Please complete this questionnaire before you come for your appointment. Be sure to call us as soon
Dear Yoga Therapy Case Study Applicant,
Dear Yoga Therapy Case Study Applicant, Many thanks for your interest in our program. We will do our best to secure a spot for you in our on- going free Saturday Clinic. Our only request is your commitment
SEEDS OF HOPE FAMILY CHIROPRACTIC HEALTH HISTORY
SEEDS OF HOPE FAMILY CHIROPRACTIC HEALTH HISTORY Welcome! PLEASE PRINT CLEARLY PERSONAL DATA Today s Date First name MI: Last name: Nickname Gender M F Age Date of Birth SS# (optional) Current address
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2001 Santa Monica Blvd., Suite #760W Santa Monica, CA 90404 (310) 582-7474 (Office) (310) 582-7481 (Fax) http://california.providence.org/saint-johns/services/orthopedics/ http://www.totaljoints.net/ Dear
Birth Date Age Social Security # Marital Status (circle) Have you had chiropractic care in the past? Yes No If yes, how long ago?
136 Wilson Pike Circle Brentwood, TN 37027 NEW PATIENT INFORMATION Please complete ALL questions below unless otherwise indicated. First Name Last Name Date Street Address City State Zip Cell Phone Provider
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
PAR-Q & LIABILITY WAIVER
PAR-Q & LIABILITY WAIVER Full name: Address: Post code: Mobile: Home phone: Email address: Date of Birth: Occupation: Emergency contact name: Relationship to you: Emergency contact phone number: Tara Blackaby