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1 New Beginnings Myofascial Therapy LLC Sheri Brimm, P.T. Cell Work MFR (1637) Toll Free MFR-0291 Fax INITIAL EVALUATION SUBJECTIVE REPORT Today's Date Date of Birth Name Address City State Zip Phone: Home Cell Emergency contact/relation: Emergency Phone: Contact Your Occupation Work_ Primary Care Physician, Referring Physician or therapist Address Phone Your Insurance Provider How did you hear about me? The following is very important in the evaluation process. Please fill out these forms as specifically as possible to provide me with a clear picture of your present pain and functional status. Describe the primary complaints that bring you here today. When and how did your symptom(s) begin? Date: List the activities that you are having difficulty with or are unable to do currently due to this condition. (work, housework, yardwork, athletic activities, walking etc). SYMPTOMS CURRENTLY EXPERIENCING: PAIN: On a Scale from 0-10 (0=painfree, 10=worst imaginable pain), how would you rate your pain? Location of Pain: Presently(0-10)_
2 Best Worst Other location: Presently(0-10)_ Best Worst Numbness or Tingling? (describe) Headache / Dizziness? (describe) Sleep disturbance? Anxiety / stress / depression symptoms? Stiffness / tightness? What makes the symptoms better? What makes the symptoms worse? Have you ever received any treatment? Describe previous treatments Please indicate all past medical history as it may be relevant to your treatment (even as a child). SURGERIES: (list all procedures for which you have received anesthesia even minor ones) 1. Date: Type: 2. Date: Type: 3. Date: Type: ALLERGIES: 1. MEDICINE: No Known Allergies or (LIST BELOW) Do you take shots? 2. LATEX? YES NO FOODS: 3. CHEMICALS / ENVIRONMENTAL: LIST ALL PAST HISTORY AND ALL CURRENT PROBLEMS FOR WHICH RECEIVE MEDICAL CARE FROM PHYSICIAN ROUTINELY SUCH AS DIABETES, HIGH BLOOD PRESSURE, HIGH CHOLESTROL, LOW THYROID ETC HAVE YOU BEEN IN THE HOSPITAL? DESCRIBE WHAT FOR AND WHEN
3 List ALL medications which, you are currently taking, the problem for which you are using them, the dose, and their effectiveness. (Include supplements, herbal and homeopathic remedies). Medication, Dose/Amt. per day Is there a chance you may be pregnant at this time? Yes HAVE YOU EVER HAD ANY OF THE FOLLOWING: (NO or list details if applicable) 1. HEART ATTACK / CONGESTIVE HEART FAILURE / HEART CATH / HEART SURGERY (Describe & Dates) No 2. SEIZURES, STROKE, TIA, HEAD INJURY, Concussion, Dizziness_ 3. CHIARI MALFORMATION, VERTEBRAL ARTERY SYNDROME, SEVERE WHIPLASH or LIGAMENT INSTABILITY IN NECK (Date)_ 4. BLOOD CLOTS or TAKE ANTICOAGULANT MEDICATION SUCH AS COUMADIN / PLAVIX / ASPIRIN? 5. PACEMAKER, HEART ARRHYTHMIA/ CIRCULATION PROBLEMS_ LUNG / EMPHYSEMA / COPD / SEVERE ALLERGY / ASTHMA? YES NO DIABETES: YES NO DISEASES OF KIDNEY, LIVER, STOMACH, GALL BLADDER, PANCREAS, COLON? 1. CANCER, LEUKEMIA? (Describe) 2. BROKEN BONES / ORTHOPEDIC INJURIES /ARTHRITIS / FIBROMYALGIA (describe) OSTEOPOROSIS : YES_ No 5. SYSTEMIC DISEASE / AUTOIMMUNE DISEASES SUCH AS MS, RA, ALS, Lupus? 6. ANXIETY, DEPRESSION, ADD/ADHD, ASPERGER'S, AUTISM, PTSD, BIPOLAR DISORDER, SCHIZOAFFECTIVE DISORDER, Etc? 7. Have you ever been or recently been attacked, hit, kicked, slapped, punched, abused sexually? (emotional trauma may be relevant to your therapy) 8. List Car accidents, Falls, Other traumas, scars you have.
4 DO YOU CURRENTLY HAVE ANY OF THESE SYMPTOMS ( Check if applicable) Sprains/Strains Muscle tear/ sore muscles Tendonitis/bursitis Stiff achy joints Swollen joints or limbs Weakness or Fatigue Trembling/twitching muscles Menstrual/ Pelvic area pain Breast tenderness / numbness /lump Sweaty palms Cold hands/feet Night sweats Hot Flashes Blushing/flushed face Heart palpitations / arrhythmias_ Heartburn/indigestion abdominal pain Frequent urination or difficulty urinating Dark colored urine Painful urination Urinary leakage Bowel leakage constipation Diarrhea Pale or light colored stools Black, tarry stools Skin rashes or open wounds Itching or burning of skin Grinding of teeth (TMJ) or popping of jaw Mouth sores Problems with teeth Weight Change >15 lbs Tension headaches or migraines_ Sinusitis Depression/Anxiety Visual Disturbances or vision changes Feeling faint or dizzy INFORMED CONSENT TO USE OF OILS / HANDS ON TECHNIQUES : Do you have any chemical sensitivities to scents or oils or lotions? I use therapeutic grade essential oils in therapy sometimes and if you do not wish me to use those or have specific problems please let me know. I want you to use essential oils during therapy. YES No INITIALS Myofascial release is a hands on technique which is most effective with direct contact with skin. You may wear shorts, sports bra, or bathing suit and /or underwear. Sometimes internal techniques can be performed in rectum or vagina to assist you with pelvic pain, tailbone pain, or techniques in the mouth for neck/head/jaw pain. By signing below you agree to hands on therapy in any areas required to properly treat you. You may choose during any session to tell therapist if you are uncomfortable with any techniques and we can modify or find other techniques or perform work over clothing, which may not be as effective. Please notify therapist of any concerns you have regarding treatment. You may also bring a family member into the session with you if you would like for support / comfort. MFR also can elicit emotional healing responses. Please know that you are encouraged to seek a professional counselor for any emotional or mental problems. We are here to support your healing but we are not licensed professional counselors. MFR can also elicit healing crisis which may cause temporary soreness, increase of pain, spasms, twitching/jerking of muscles, detoxing symptoms such as nausea, diarrhea, vaginal spotting, headache, or dizziness. This effect is usually temporary hours and is part of the process of healing. Please contact your doctor or emergency room if you have any symptoms that are severe or concerning. I CONSENT TO HANDS ON TREATMENT AS DESCRIBED CLIENT SIGNATURE DATE:
5 New Beginnings Myofascial Therapy, LLC NOTICE OF ADVICE: The State of Tennessee allows direct access to Physical Therapy without a referral from a doctor, dentist or nurse practitioner for a short time. If your symptoms do not improve with PT services, I am required to consult with your physician or refer you to a medical provider for further consultation within 15 days of the evaluation. If treatment beyond 15 days is needed, a referral and/ or signature on PT eval plan of care by a physician will be requested. I cannot see you at all beyond 30 days without a physician consultation or order. This notice is to advise you that your health insurance company may or may not cover PT without a referral, while they may cover PT with a referral. You should understand that your insurance provider may not reimburse therapy services and services rendered are not contingent on reimbursement. New Beginnings Myofascial Therapy does not pre-authorize or bill insurance directly at this time, but if you wish to submit for reimbursement on your own behalf, we can provide copies of the paperwork upon request so that you can do so. You will need to check with your insurance carrier prior to the evaluation to determine if medical referral orders and preauthorization is required for physical therapy. Due to stringent Medicare restrictions, New Beginnings Myofascial Therapy cannot see any MEDICARE recipients for cash for medically based covered physical therapy services, but we will be happy to refer you to a Medicare provider. If you have Medicare you can only participate in the wellness program (non-covered services) cash pay and cannot apply for reimbursement. Also, be aware that there is a 24-hour cancellation policy. You are responsible for full payment of the missed/cancelled session. This ensures that open appointment times are not left void, while other patients may be on a waiting list to receive treatment. By signing this document you agree to adhere to this policy. There is a $40 service fee for checks with insufficient funds. Please sign and date below that you have read understand this advice. Thank you. By signing below you are consenting to evaluation and further treatments, verifying the information you have given above is correct to the best of your knowledge, and agreeing to the cancellation / no show / check policies. Signature: Date:
6 NEW BEGINNINGS MYOFASCIAL THERAPY LLC HIPAA PRIVACY PRACTICES NOTICE I understand that New Beginnings Myofascial Therapy LLC 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. I authorize New Beginnings Myofascial Therapy LLC, and/or Sheri Brimm PT to consult and share documentation of my treatment with physicians, medical or health providers, or insurance companies involved in my care. Further release of medical records will not be performed unless authorized by me. New Beginnings Myofascial Therapy may also utilize my cell phone number, home phone number, address, or postal address to send me notifications of appointments and notify me of services or information that may be helpful or relevant to me. New Beginnings Myofascial Therapy will not share information with other entities unless authorized by me. SIGNATURE DATE:
P.T INITIAL EVALUATION SUBJECTIVE REPORT TODAYS DATE:
New Beginnings Myofascial Therapy LLC At Optimal Health and Performance 13 North Oak St Cookeville TN 38501 Sheri Brimm, P.T. Cell 931-319-0291 Office 931-651-1390 Fax 931-651-1391 INITIAL EVALUATION SUBJECTIVE
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Patient Information Name ----------------------------------------------------------- Address --------------------------------------------------------- City State Zip Home Phone -------------------------
Who? When? Results? Please Mark P For In The Past OR Mark C For Currently Have:
T, CD, E, C New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Email Address Occupation Employer s Name Single / Married / Divorced / Widowed
New Patient Information
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Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic th Avenue Surrey BC V4A 2H9 Tel: Fax:
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BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ
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Practice Member Profile
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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
Chiropractic Case History/Patient Information
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PATIENT INFORMATION FORM
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3. How Long Has This Been An Issue?
NEW PATIENT INTAKE FORM Aspire Chiropractic 124 W Harwood Rd. Ste. B Hurst, TX 76054 Name: Occupation: DOB: Age: Sex: Male Female Employer: Marital Status: Single Married Other Name/Age of Kids: Phone:
Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon)
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