Patient Health History and Information

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Audra Hollie Dawson
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Name: Patient Health History and Information DOB: Date: / / Age: Height: Weight: Dominant hand: R L Could you be or are you pregnant: Yes No Sex: M F Reason for Therapy: Please describe how your

1 Name: Patient Health History and Information DOB: Date: / / Age: Height: Weight: Dominant hand: R L Could you be or are you pregnant: Yes No Sex: M F Reason for Therapy: Please describe how your injury/problem occurred (i.e. fall, activity, w ork, auto, unknow n): Date of injury or onset of symptoms: / / Recent surgery? Yes No Date: / / Type: Please list any treatment you have received for this condition (i.e. Therapy, Chiropractor): For this condition have you had any of the following? None X-ray / / MRI / CT scan / / Injection: type: / / Surgery: type: / / Other: / / Using the key below indicate on the body diagrams where your symptoms are located. X=Pain //= Numbness O=Tingling Please rate your pain (0=none, 1=minimal, 10=severe) At worst: At present: At best: Please describe your pain/symptoms Constant Intermittent Increasing Decreasing Staying the same Sharp Dull Aching Burning Weakness Throbbing Other: Which side are we seeing you for?: Right Left What makes your symptoms worse? (i.e. heat, cold, rest, activity) What makes your symptoms better? (i.e. heat, cold, rest, activity) Please indicate your current limitations due to injury: Sitting: Standing: Sleeping: Going from sit to stand Walking Lying down Up/Down stairs Reaching Squatting Bending Looking overhead Taking a deep breath Swallowing Talking / Chewing / Yawning / All (circle one) Turning head Driving Work Self care / Hygiene Home activities Repetitive activities Sports / Recreation Other: What are your goals for therapy? Since your symptoms began have you had any of the following: Fever / Chills Yes No Unexplained weight change Yes No Nausea / Vomiting Yes No Night sweats / pain Yes No Numbness genital/anal area Yes No Problems with vision / hearing / speech Yes No Dizziness / Fainting Yes No Difficulty with bowel/bladder function Yes No Unexplained weakness Yes No Other: Yes No Headaches Yes No Who referred you to Physical Therapy? Primary Physician: How did you hear about OSI Physical Therapy? Physician Friend/relative Website Previous patient Self Coach Other Med Hx pg. 1 of 2 08/12//14

2 Name GENERAL HEALTH HISTORY: DOB Have you had any falls or near falls in the past year? Yes No Rate your overall health: Excellent Good Average Poor Do you exercise? Yes No x/week Do you smoke? Yes No Do you drink caffeinated beverages? Yes No /week Occupation/job title: Self Student Full time Part time Retired Unemployed Living Situation: Alone Spouse Family Others Physical activities at work: Sitting Standing Computer use Phone use Repetitive/Heavy lifting Other: Employer: Current work duty: Full duty Restricted duty Work days missed: QRC (if you have one): Have you or anyone in your immediate (brother, sister, parent, grandparent) family ever been diagnosed with any of the following: Allergies Self Family No Kidney problems Self Family No Asthma Self Family No Metal Implants Self Family No Cancer Self Family No Thyroid problems Self Family No High blood pressure Self Family No Epilepsy/dizziness Self Family No Heart trouble/angina Self Family No Tuberculosis Self Family No Diabetes Self Family No Anemia/blood disorder Self Family No Stroke Self Family No Multiple Sclerosis Self Family No Osteoporosis Self Family No Circular/vascular problems Self Family No Osteoarthritis Self Family No Chemical dependency Self Family No Rheumatoid arthritis Self Family No Pace maker Self Family No Depression Self Family No AIDS/HIV Self Family No Headaches Self Family No Hepatitis Self Family No Bladder/bowel problems Self Family No Other: Self Family No Over the past 2 weeks, how often have you been bothered by any of the following problems? 1. Little interest in the pleasure of doing things: 0- Not at all 1- Several days 2- More than half the days 3- Nearly every day 2. Feeling down, depressed or hopeless: 0- Not at all 1- Several days 2- More than half the days 3- Nearly every day Are there any other issues/concerns that you think we should know about that may or may not effect your ability to benefit from physical/occupational therapy treatment: Yes No Patient Signature: Date / / Reviewed by Therapist: Date / / MD follow-up: / / None Scheduled With-in 90days of last Medical history completion (date and initial any changes) Medical History reviewed by patient, changes noted and reviewed by therapist. Patient Signature: Date / / Reviewed by Therapist: Date / / Med. Hx pg. 2 of 2 08/12/14

4 OSI CANCEL / NO SHOW POLICY: HOW IT AFFECTS YOU Thank you for choosing OSI Physical Therapy as your physical therapy provider. We are sincerely concerned with helping you meet your goals of therapy. In order to do this, it is important that you attend all scheduled therapy appointments. Consistent attendance allows you and your therapist to progress your treatment program which will result in quicker recovery and better outcomes. We realize that there are times when unforeseen circumstances make it impossible to attend your scheduled appointment. If this happens, please give us as much notice as possible so we can reschedule the time for another patient and find another time for your appointment. Canceling an appointment with short notice or not showing up for appointment takes up clinic time that could benefit another person. In order to enforce this policy, you may be charged $30 if you cancel an appointment less than 24 hours before your appointment time or do not show for an appointment. Canceling or no showing for more than three appointments will unfortunately limit your ability to schedule advanced appointments and may result in allowing same day scheduling only. We want to make your physical therapy experience as beneficial as possible and your commitment is a very important part of this. If you know you are going to have a difficult time making your appointments, please discuss this with you therapist. We will try to accommodate your needs. Thank you

9 Dear Medicare Customer, (651) NOTICE OF FINANCIAL LIMITATION Medicare has placed an annual financial limit (cap) on therapy services. There are two separate therapy cap, which limit the amount of services that will be covered in a calendar year for each Medicare beneficiary. The calendar year starts on January 1 and ends on December 31. There is an exception process by which Medicare will pay for services beyond the cap if the services are determined to be medically necessary. HISTORY In 1997 Congress attempted to control Medicare costs by imposing a financial limitation on therapy services. Since that time, Congress has acted three times to place a moratorium on the cap, blocking its implementation. More recently, the exception process was put in place to allow customers to receive necessary therapy from the provider of their choice. The 2015 limitations (caps) are as follows: $1, for Physical Therapy and Speech Therapy services combined, and $1, for Occupational Therapy services The therapy caps are the ONLY capped services under Medicare. Services provided in hospital-based outpatient clinics are exempt from the cap. A NEW PROCESS WAS IMPLEMENTED ON OCTOBER 1, 2012: As of October 1, 2012, services that exceed $3700 will require a review process by the Centers for Medicare Services (CMS) the insurance company contracts with Medicare. That means that CMS will do a Manual Medical Review asking for more documentation showing your care is Medically Necessary. They will decide whether to authorize us to provide that therapy. So you can be assured that we will advocate on your behalf. You may be asked to sign an Advance Beneficiary Notice of Noncoverage (ABN) so that you are aware of the situation that your services exceed the $3700 and that Medicare may determine that those services are not medically necessary. If that is the case, then you are responsible for the charges. HOW DOES THE CAP WORK? Medicare bases the cap on the allowable charges covered by Medicare. In other words, it is based on what Medicare considers the maximum reimbursement that it will make for a service. After you have met your Medicare deductible of $140.00, Medicare will pay 80% of the $1940= $ You will be responsible for 20% of the $1940 = $ These numbers are based on the annual therapy cap. 1/21/2014

10 WHAT HAPPENS WHEN THE CAP IS REACHED? If your therapy services will exceed the cap you have some choices. You can: 1. Continue services under the exception process, if you qualify, OR 2. Continue therapy under a secondary insurance plan if you have one, OR 3. Continue therapy on a self-pay basis, OR 4. Discharge yourself from therapy. DISCLAIMER We do not support the limitation that Congress has imposed on the benefits that you receive under Medicare. We will work with you to ensure that you receive the medically necessary care that you need. The American Physical Therapy Association (APTA) is working hard to repeal the cap once and for all. Please contact your U.S. Senators and Representative and urge that they remove this unfair and arbitrary cap on rehabilitation services. If you have questions about Medicare s Financial Limitation policy call the National Government Services (NGS) toll free /21/2014

11 OSI Physical Therapy: Locations & Directions Forest Lake 146 North Lake Street, Suite 11 (park in back) Phone (651) Fax (651) From the intersection of Lake Street and Broadway, go north on Lake Street/Highway 61 one block. Turn left on NW 2nd Avenue. Lake Elmo/Woodbury High Pointe Health Campus 8650 Hudson Boulevard, Suite 300 Phone (651) Fax (651) From the intersection of Interstate 94 and Radio Drive/Inwood exit, go north on Inwood. Go East on Hudson Boulevard. Turn left to High Pointe Health Campus. Maplewood Maple Avenue, Suite Phone (651) Fax (651) From the intersection of Highway and Avenue, go on Avenue. Turn left on. Shoreview 404 W. Highway 96, Suite C Phone (651) Fax (651) From the intersection of 35W and Highway 96, go east on 96 to Hodgson Road or from the intersection of Highway 96 and 35E, take 96 west to Hogson Road. Turn south on Hodgson Road (entrance off Hodgson). Turn right on Bridge Court East and follow Bridge Court to the office. Stillwater 1700 Tower Drive West Phone (651) Fax (651) From the intersection of Highway 36 and Washington Avenue, go north on Washington Avenue 1 block. Turn right onto Tower Drive. West St. Paul Lafayette Square Shopping Center 433 East Mendota Road Phone (651) Fax (651) From the intersection of HIghway 52 and East Mendota Road, go west on East Mendota Road 1 block. Turn right into Lafayette Square Shopping Center. White Bear Lake Parkway Pointe Business Center 4463 White Bear Parkway, Suite 108 Phone (651) Fax (651) From the intersection of Highway 96 and White Bear Parkway, go Somerset, WI 709 Rivard Street Phone ) Fax (715) From Highway 35 North, turn north on LaGrandeur Road. Turn right on Rivard Street. Online pre-registration: Appointments: or Revised /1

Patient Health History and Information

Patient Health History and Information Date: Age: Height: Weight: Sex: M F Dominant hand: R L Could you be or are you pregnant: Y N Reason for Therapy: Date of injury/onset of symptoms: / / Please describe