Welcome to Lone Lake Physical Therapy!
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- Barbara Hampton
- 5 years ago
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1 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 min What you should know before your first session: Lone Lake Physical Therapy provides high quality individualized care. By choosing our facility, you will be working with one of our highly skilled practitioners. Each practitioner has their own specialty. Whether it is movement education, fascial tension normalization, balance, neurological rehabilitation or soft tissue work; your therapist will individually work with you to create a personalized treatment plan. We will help to alleviate the pain and limitation from your condition, and help you to be as active as possible. What you should wear for physical therapy: Please wear comfortable, loose, non-restrictive clothing or bring something to change into. Most treatments are provided through the clothing (with a few exceptions where skin contact is a necessity). Some clothing can make treatment more difficult or more uncomfortable for you. Female clients should avoid wearing underwire bras (if possible) as these often get in the way and can be uncomfortable during several of the techniques. Treatments can require movements that may seem immodest without proper clothing, please do not wear skirts or dresses. Please avoid wearing jeans, belts, or heavy shirts. What to do after your first session: Please allow yourself 2-3 days to assess the impact of your treatment (this means to avoid strenuous exercise stressing healing tissues too quickly will encourage them to revert to their former pain producing patterns). Rest and hydration are the best things you can do. A 15 min walk after treatment is often helpful. PLEASE NOTE: Our main goal is to help you meet your goals. Sometimes you may benefit from working with more than one specialist, or a different therapist than the one you start with. Your therapist will complete regular evaluations of your progress and will discuss with you if the opportunity to work with another practitioner would help you maximize your physical potential.
2 At LLPT we consider ourselves partners on your path to improved wellbeing. Other health care pracitioners may be important for your optimal health and we respect and encourage you to have a whole team behind you. However, the most important person on this team is you. Patient Responsibility: As you commit yourself to better health, you have some responsibilities we would like you to keep in mind. Please initial below, to let us know that you have read these guidelines and agree to make them a priority. 1. Regular movement. Your therapist will give you exercises, postural cues, and ways to avoid reproducing your pain or strengthen your body to help prevent injury. These exercises need to be done every day in order to maximize your recovery. In addition, we want you to just move- walk, bike, swim, dance whatever you enjoy, at least 30 min every day in addition to your normal daily activities. 2. Stress control. Sometimes we cannot control the stressors in our lives, but many times we can. What increases your stress level? This is a hindrance to your wellbeing. If you cannot change your stressors, what can you do to help minimize the stress level within your body? We are here to help if you need ideas or support. 3. Diet. What is happening in your digestive system is being shown more and more to affect your physical health and emotional wellbeing. Creating a healthy internal environment starts with what you chose to eat. If you want to prevent exacerbation of your condition and maximize your ability to heal, a healthy diet is the best place to start. We can help with guidance to point you to specialists if you need that as a part of your team. 4. Rest. Both your sleep at night, and having some rest time during the day is critical for healing and preventing disease, learning and improving mood. Make a commitment to yourself to set up routines to sleep well and take a little time for yourself each day. I promise to participate fully as a member of my health care team. I will make sound choices regarding my treatment plan based on the information provided by my therapist and other members of my health care team, and my experience of those suggestions. I agree to participate in the self-care program we select. I promise to inform my therapist any time I feel uncomfortable or that a treatment is not working towards my well-being.
3 NAME: DATE OF BIRTH: ADDRESS: CITY: STATE: ZIP: PHONE: MOBILE: WORK: ADDRESS: May we use this address for contacting you regarding: your care at LLPT (appointment reminders, etc) LLPT information and events *please note that we do use not encrypted s at LLPT, although our service is HIPPA compliant EMPLOYER: POSITION: EMERGENCY CONTACT: RELATIONSHIP: PHONE: PRIMARY CARE PHYSICIAN: PHONE: REFERRING PHYSICIAN: PHONE: How did you hear about Lone Lake Physical Therapy? NOTICE OF PRIVACY POLICY: I have reviewed the Privacy Policy Notice of Lone Lake Physical Therapy, LLC CANCELLATION/NO SHOW POLICY: 24 hours notice is required to cancel an appointment (for a Monday appointment please let us know by Friday the week before). You will be charged a $50 fee if you cancel with less than 24 hours notice or do not show up for your appointment. Insurance companies will not pay this fee. I agree to the stated cancellation/no show policy.
4 CONSENT FOR TREATMENT: I authorize and consent to physical therapy/massage services from Lone Lake Physical Therapy, LLC. I have reported all health conditions that I am aware of and will inform my therapist of any changes in my health or concerns regarding care in this facility. CLIENT PRINTED NAME: CLIENT SIGNATURE: CONSENT TO DISCUSS MEDICAL CARE: I authorize Lone Lake Physical Therapy, LLC to discuss my medical information with the individuals I have listed below, in addition to my referring provider and insurance company. NAME: NAME: NAME: RELATIONSHIP: RELATIONSHIP: RELATIONSHIP: This authorization shall remain effective unless revoked by me in writing. CONSENT FOR TREATMENT OF A MINOR: I,, the parent or legal guardian of my child, authorize and consent to physical therapy services from Lone Lake Physical Therapy, LLC for my child. This authorization shall remain effective unless revoked by me in writing. PARENT/GUARDIAN OF _
5 SELF-PAY: LLPT will accept self-pay for its services if you either do not have insurance, we are not a provider with your insurance, or for a service your insurance company does not cover (like wellness care). Payment must be paid the day of your service, we are unable to bill for self-pay treatments. The physical therapy Self Pay fee is $125.00/hr. and the massage therapy Self Pay fee is $85.00/hr. FINANCIAL AGREEMENT FOR SELF-PAY: I am financially responsible for the payment of balance due for services received from Lone Lake Physical Therapy, LLC at the time of service. INSURANCE BILLING: LLPT is a preferred provider for Physical Therapy with Regence, Uniform Medical, Premera, LifeWise, Kaiser, L&I, and Medicare. Massage is covered by Premera, L&I and motor vehicle claims. FINANCIAL AGREEMENT FOR BILLING INSURANCE: The information I have provided is correct to the best of my knowledge. I understand that Lone Lake Physical Therapy, LLC may bill my insurance company for the services provided. I am financially responsible for deductibles, coinsurance, co-pays and services not covered by my insurance provider. I authorize LLPT to furnish the responsible insurance company and other authorized parties with necessary information to process physical therapy claims on my behalf. I authorize the payment of medical benefits to Lone Lake Physical Therapy. I am financially responsible for the payment of balance due, including all fees denied for services based on inaccurate information provided on this form. The below Physical Therapy/Massage benefits are accurate to the best of my knowledge. **PLEASE ATTACH A COPY OF YOUR INSURANCE CARD**
6 ARE YOU ENROLLED IN MEDICARE PART B? YES NO PRIMARY INSURANCE: PRIMARY INSURANCE: POLICY ID # POLICY GROUP # CLAIM # SUBSCRIBER S NAME: SUBSCRIBER S DATE OF BIRTH: SUBSCRIBER RELATION TO PATIENT: SELF SPOUSE PARENT OTHER DEDUCTIBLE: $ (Your deductible is the amount you need to pay for covered health care services before your health insurance or plan begins to pay. This means that you will be responsible to pay 100% of the physical therapy charges you accrue until you have met this amount total for all your medical services for the year, in addition to what is listed as your co-pay or co-insurance.) CO-PAY: $ (This fee is paid at the time of service for each session.) CO-INSURANCE: % (This is a % of the physical therapy charges that you will be responsible for after your insurance has paid the remaining %. ) ALLOWED NUMBER OF PT VISITS: ALLOWED NUMBER OF MASSAGE VISITS: Please verify if PT and massage are combined benefits on your plan: Yes No SECONDARY INSURANCE: SECONDARY INSURANCE: POLICY ID # POLICY GROUP # CLAIM # SUBSCRIBER S NAME: SUBSCRIBER S DATE OF BIRTH: SUBSCRIBER RELATION TO PATIENT: SELF SPOUSE PARENT OTHER
7 Date of initial evaluation: Diagnosis Code: Post Surgical? Yes No Condition bringing you to physical therapy/massage: When did this start? Please mark the areas affected by your current condition on the pictures to the right: Over all my condition is (circle one): getting better getting worse staying the same Right Left Left Right Previous treatment for this condition: Current exercise habits: All Current Medications: * ATTACH LIST IF NEEDED Medication name Dosage Frequency Route of administration Past Medical History (include all implanted devices: stents, IUD, pacemaker etc:) * ATTACH extra sheet IF NEEDED
8 How limited? List 3 things you have trouble doing because of your condition: Mild Mild-Mod Mod- Severe Severe Current Pain Level Mild Uncomfortable Miserable Intense/Horrible CIRCLE YOUR CURRENT PAIN LEVEL How often are you in pain? 0-25% 26-50% 51-75% % Please list your goals for physical therapy/massage: Other concerns/conditions you would like to discuss with your therapist:
9 HEALTH HISTORY Current Past GENERAL Current Past SKIN CONDITIONS Headaches Neck, shoulder, or arm pain ALLERGIES Low back, hip or leg pain Sleep disturbances, fatigue NERVOUS SYSTEM Infections Head injuries/concussions Fever Dizziness Sinus Ringing in ears Loss of memory/confusion MUSCULOSKELETAL Numbness Rheumatoid condition Balance issues Osteoarthritis Difficulty walking Osteoporosis Falls Scoliosis Tingling Disc/spine problems Radiating/shooting pain TMJ Cramps/spasms/muscle pain DIGESTIVE ISSUES Sprains/strains Bowel dysfunction Tendonitis Gas, bloating Bursitis Bladder/kidney dysfunction Abdominal pain CARDIOVASCULAR Heart disease OTHER Blood clots Depression Stroke Thyroid Dysfunction Lymphedema/swelling Diabetes High blood pressure Pregnancy Low blood pressure Painful Menses Irregular heart beat Poor circulation Chest pain Shortness of breath HABITS Asthma Tobacco COPD Alcohol Drugs CANCER Coffee
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Cascadia Chiropractic Centre
Name: Cascadia Chiropractic Centre New Patient Information & Clinical Record Date: Date of Birth: Your age: Care Card #: Address: City/Prov: Postal Code: Phone: Cell: Work Phone: E-mail Address: Marital
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
1. What is your chief complaint? Why are you seeking physical therapy treatment? 2. Explain how and when your injury/symptoms occurred:
Patient History Information Patient Name: Height: ft in. Weight: lbs. 1. What is your chief complaint? Why are you seeking physical therapy treatment? 2. Explain how and when your injury/symptoms occurred:
PATIENT NAME DATE CONSULTATION QUESTIONNAIRE
CONSULTATION QUESTIONNAIRE 1. What is your major symptom? 2. What does this prevent you from doing or enjoying? 3. If this is a recurrence, when was the first time you noticed this problem? How did it
CHIROPRACTIC EXPERIENCE ABOUT YOU REASON FOR THIS VISIT HEALTH HABITS MEDICATIONS YOU TAKE SUPPLEMENTS YOU TAKE
ABOUT YOU CHIROPRACTIC EXPERIENCE NAME: ADDRESS: CITY: HOME PHONE: EMAIL ADDRESS: STATE/ZIP CODE: CELL PHONE: WHO REFERRED YOU TO OUR OFFICE? HAVE YOU SEEN OR HEARD OF OUR OFFICE BECAUSE OF ( ALL THAT
WEBSTER CHIROPRACTIC CARE
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CHIROPRACTIC NEW PATIENT FORM REASON FOR VISIT
DR. ANN IZARD, B.COMM, DC DOCTOR OF CHIROPRACTIC 4353 HASTINGS STREET BURNABY, BC V5C 2J7 TEL: 604.293.2941 FAX: 604.298.2941 WWW.BHIHC.COM WWW.ANNIZARD.COM FULL NAME: DATE OF BIRTH (DD/MM/YYYY): STREET
ESSENTIAL ELEMENT Massage & Bodywork
Health Information Alchemy s ESSENTIAL ELEMENT Massage & Bodywork Client Contact Information Client Name: Date of Birth: Gender: M or F (circle one) Address: Email: Occupation: Referred by: Emergency contact:
Date. Patient General Information
Date John D. Belde, DC Jonas T. Johnson, DC Kelley McGowan, PT 211 Hwy 25, P.O. Box 717 Monticello, MN 55362 763.295.4105 Patient General Information Name Date of Birth Gender Address Social Security No.
Personal &Work Information Date: Patient Name: Age: City: State: Zip: Primary Care Physician: PCP Phone:
Personal &Work Information Date: Patient Name: Age: Birth Date: / / Preferred Name: Gender: Home Phone: Address: Mobile Phone: City: State: Zip: Occupation: Employer: Work Phone: Email: Emergency Contact:
New Patient Information
Personal Information Last Name First Name Middle Initial Address: Street Unit # City Province Postal Code Date of Birth (Day/Month/Year) Home Phone # Work Phone # Cell Phone # May the clinic leave you
PERSONAL INJURY QUESTIONNAIRE
PERSONAL INJURY QUESTIONNAIRE Name Date of Birth Age Address City State Zip NATURE OF ACCIDENT: 1. Date of Accident Time of Day (AM / PM) 2. Please state how the accident happened in your own words: 3.
Family First Chiropractic
Personal Information Title: (Check one) Mr. Mrs. Ms. Miss Other First Name Middle Initial Last Name Street City State Zip Code Email Home Phone ( ) - Cell Phone ( ) - Date of Birth / / Sex: Male Female
Cascadia Chiropractic Centre
Name: Address: Dr. Simpson Leung Cascadia Chiropractic Centre New Patient Information & Clinical Record Date: City: Province: Postal Code: Phone: Cell: Work Phone: Date of Birth: E-mail Address: Care Card
PATIENTS DEMOGRAPHICS
PATIENTS DEMOGRAPHICS Date: First Name MI Last Name Sex: M or F (Circle one) Age: Address: City: State: Zip Code: Home Telephone: Work Telephone: Cell/Pager No: Date of Birth: Single: Married: Social Security
PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
PATIENT REGISTRATION Patient's Name (Last, First, MI): Date Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: PERSON TO NOTIFY
KEY TO LIFE CHIROPRACTIC
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Physical Evidence Chiropractic 7035 Beracasa Way, Suite 103 Boca Raton Florida, Phone# (561) Fax# (561)
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MVA Patient Health Record
Name: Date: AHC #: Email Address: Under Canada s new anti-spam legislation, we are required to ask you for your consent to contact you via email for appointment reminders and information regarding your
About Your Ventricular Assist Device (VAD) Surgery
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PATIENT SIGNATURE: DOB: Date:
CINCINNATI PAIN PHYSICIANS, LLC (CPP) ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES By signing below, I acknowledge that I have received a copy of CPP s Notice of Privacy Practices. The Notice
New Practice Member Paperwork
Cornerstone Family Chiropractic Health Information Form 928.237.9477 www.cfc4familyhealth.com 2225 E State Route 69 Suite A Prescott, AZ 86301 New Practice Member Paperwork This form is for adults only.