1. What is your chief complaint? Why are you seeking physical therapy treatment? 2. Explain how and when your injury/symptoms occurred:
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- Penelope Cobb
- 5 years ago
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1 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: 3. Have you had this problem or anything like this before? Y/N. If yes, explain 4. What activities make your pain worse? When is your pain worse (i.e. morning, night) What activities are limited due to pain? 5. Have you had any diagnostic test for this current problem? X-ray date/results: MRI date/results: Other test: 6. (a) On a scale of 0-10, with 0 being no pain at all and 10 being the worst pain imaginable, how would you rate your pain RIGHT NOW? (b) On the same scale, how would you rate your USUAL level of pain during the last week? (c) On the same scale, how would you rate your BEST level of pain during the last week? 1
2 Patient Name: (d) On the same scale, how would you rate your WORST level of pain during the last week? 7. Please shade all areas of pain/discomfort. Describe any areas of abnormal sensations. (such as tingling, numbness, sharp, shooting, aching, stabbing) 9. How is your general health? Good *Fair *Poor *fair or poor please explain: 10. Do you participate in 2 ½ hours (150 minutes) of moderate-intensity aerobic physical activity EACH WEEK? Yes No 11. Do you work? Y/N If yes, what type of work do you do: What are the physical requirements of your job? Are you able to perform your job without difficulty and/or pain? Y/N If no, please explain: 2
3 Patient Name: 12. Please check any of the following health conditions that apply to you: Autoimmune Disease Hepatitis HIV Lupus Diabetes Type I Hypothyroidism Hyperthyroidism Inflammatory Bowel Disease (Crohn s) Multiple Sclerosis Cardiovascular High Blood Pressure Heart Disease Heart Attack Peripheral Vascular Disease (PVD) Endocrine System Diabetes Type II Musculoskeletal Osteoarthritis Fibromyalgia Osteoporosis Gastrointestinal Disease Reflux GERDs Peptic Ulcer Neurological Stroke or TIA Parkinson Disease Chronic Headaches/Migraines Pulmonary Asthma COPD Psychology Depression Anxiety Panic Disorder Sensory Hearing Impairment Visual Impairments Balance Problems (Vertigo, Dizziness Current or history of Cancer: Location: Other health conditions: FEMALE ONLY Menopausal Age Hysterectomy Year, Partial, Complete Incontinence: Stress Incontinence, Urge Incontinence, Mixed Incontinence Pregnancy(s) Number, Births, C- Section(s), Vaginal birth(s) Breast augmentation or reduction Tummy Tuck Other MALE ONLY Prostate problems Other 3
4 Patient Name: 13. Please check SURGERIES and the date of the surgery. SPINE Cervical spine Date Type Lumbar spine Date Type EXTREMITIES Hip Right/Left Date Type Knee Right/Left Date Type Leg/Ankle Right/Left Date Type Shoulder Right/Left Date Type Arm/wrist Right/Left Date Type GENERAL Gall Bladder (cholecystectomy) Heart Pace maker Heart Stent Heart Bypass Hernia Other 14. Are there any other health conditions that we need to be aware of that will affect your rehabilitation? 15, List all present medications you are taking: 16. What is your outcome goal with Physical Therapy? Decreasing and/or eliminating pain is always a goal. Please make your goal functional, an activity that pain is preventing or limiting you in participating or performing. 4
5 N-BALANCE PHYSICAL THERAPY NOTICE OF PRIVACY PRACTICE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY USES AND DISCLOSURES OF THE PHI (PERSONAL HEALTH INFORMATION) N-Balance Physical Therapy (NBPT) is required by law to protect the privacy of your personal health information, provide this notice about our information practices and follow the information practices that are described herein. NBPT uses your personal health information for treatment, obtaining payment for treatment, conducting internal administrative activities and evaluating the quality of care that we have provided. NBPT may use your personal health information to contact you to provide appointment reminders, or information about treatment alternatives or other health related benefits that could be of interest to you. NBPT may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, for emergencies, and when required by law. It is NBPT s policy to obtain your written authorization before disclosing your personal health information. NBPT s policy is to allow access to PHI on a need to know basis such as needed for treatment delivery, healthcare operations and related billing services. PHI includes, but not limited to, the patient/client s name, address, date of birth, age, gender, phone number, , SS#, employer information, diagnosis, prognosis, past medical history, treatment, and billing records. PATIENT/CLIENT S RIGHTS If you have provided us with written authorization to release your information, you may later revoke that authorization to stop future disclosures, this must be in writing. When paying for services out of pocket (fee for service, not filing with your insurance) you may request in writing to restrict disclosure of your PHI to any health plans. You have the right to review or obtain a copy of your PHI. There may be a nominal fee for copying of your records. You have the right to request that we correct any inaccurate or incomplete information in your records. You have the right to request a list of instance where we have disclosed your PHI for reasons other than treatment, payment or other related administrative purpose. Expect that his/her PHI will be handled, secured or disposed of in full compliance with federal privacy regulations. Has the right to see our policy and procedures we have in place for PHI protection. PATIENT/CLIENT S RESPONSIBILTIY Provide the proper picture ID at the initial visit, if no photo ID, have 2 forms of identification. If minor (under age 18), the picture of the parent of guardian must be presented. Give complete and accurate information and demographics. Adhere to department guidelines while at this facility including, but not limited to courteous interaction with other patients/clients and staff members. Do not ask about the health, condition, or progress of other patients/clients. Do not come to therapy while under the influence of alcohol or illegal drugs. CONCERNS AND COMPLAINTS If you have any concerns, or feel your PHI have been compromised please contact the Privacy Officer of NBPT at (972) It is the practice and commitment of all employees and agents of NBPT to respect and ensure the legal, ethical and moral rights of the patients/clients it serves. Patient/Client Signature Date Patient/Client Printed Name Revised Jan 2017
6 Patient Name: N-BALANCE PHYSICAL THERAPY AUTHORIZATION FOR RELEASE OF INFORMATION I. Who to Contact I hereby give permission to N-Balance Physical Therapy to disclose and discuss any information related to my medical condition(s) to/with the following family member(s), other relative(s) and/or close personal friend(s): Name Relationship Name Relationship I do not wish to give permission for additional family members, relatives or close personal friends to have access to any information regarding my medical condition(s). II. How to Contact - Check ALL that apply I wish to be contacted in the following manner: Telephone Home Phone: OK to leave message with detailed information Leave message with call-back number only Cell Phone: OK to leave message with detailed information Leave message with call-back number only Work Phone: OK to leave message with detailed information Leave message with call-back number only TEXT Messages OK to TEXT appointment reminders to this Mobile/Cellular Number Written Communication OK to send messages OK to mail to my home address OK to mail to my work/office address Address Address III. In case of an emergency contact: Name Relationship Phone Number The duration of this authorization is indefinite unless otherwise revoked in writing. I understand that requests for medical information from persons not listed above will require a specific authorization prior to the disclosure of any medical information. Signature of Patient or Legal Representative Date Form 1302 Updated 01/2017
PERSONAL INFORMATION. Date of Birth Age (Last) (First) (M.I.) Address City/State Zip. Phone # Home Work Cell
*If the reason for your visit is due to a worker s compensation injury or an automobile accident, please inform the front desk immediately. PERSONAL INFORMATION of Birth Age (Last) (First) (M.I.) Address
Name Date / / Age Male/ Female Address City State Zip
T 1 2 3 : Name _ Date / / Age Male/ Female Address City State Zip Phone: Home Cell Cell Phone Provider Email Address Date of Birth / / Occupation Employer Single / Married / Divorced / Widowed Spouse s
DR. MARK HOOPER DR. MARK THURSTON DR. NICK HERBERT
DR. MARK HOOPER DR. MARK THURSTON DR. NICK HERBERT Patient (First) (Middle) (Last) Address City State Zip E-mail address Home Phone # Cell Phone # Would you like an appointment reminder? Text( ) Call(
Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon)
Name_ Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon) For reminders do you prefer Phone Calls, Text Messages or Emails? CALL ME / TEXT ME / EMAIL ME Email Address
Patient Name: Date: Address City State Zip Code. H. Phone W. Phone Cell Phone
Patient Name: Date: Address City State Zip Code H. Phone W. Phone Cell Phone Email Address: Sex M F Marital Status M S D W Date of Birth Age SS# Occupation Employer Referred by: Have you ever received
WEBSTER CHIROPRACTIC CARE
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Who may we thank for referring you? Office Only LIST YOUR HEALTH CONCERNS BELOW. If you had the condition before, when? When did this episode start?
Name Date / / Age Male / Female Address City State Zip Phone: Home Cell Cell Phone Provider Date of Birth / / Email Address Occupation Employer s Name Single / Married / Divorced / Widowed Spouse s Name
GUPTA SPORTS & SPINE CENTER
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CORNERSTONE PAIN MANAGEMENT
SECONDARY INSURANCE PRIMARY INSURANCE CORNERSTONE PAIN MANAGEMENT PATIENT INFORMATION First Name: Dr. Mr. Mrs. Ms. Miss MI: Last Name: Social Security: Age: Date of Birth: Gender: Address: City: State:
Dear Patient, Sincerely, South Texas Bone & Joint Physical Therapy & Rehabilitation Team
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ADVANCED SPINE HEALTH AND WELLNESS CENTER DR. PAUL BACON
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Current Health Information
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History of Present Condition
Name: Date: Address: City: Province: Postal Code: Home Phone: Cell Phone: Work Phone: Email: Marital Status: Name Of Family Physician (MD): Age: Occupation: Employer: Extended Health Care Company: Policy
Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / /
Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / / Email Address: Do not have email Do not wish to provide Date of Birth: / / Gender: Male
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Family First Chiropractic
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Date: Can we leave messages on voice mail at home/work/cell? Yes No. Sex: Male Female SS#: If yes, what type? Auto Work Other.
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Dr. Janet L. Yarger 510 Baxter Road, Suite 8, Chesterfield, MO
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Aubrey M. Palestrant, MD, FSIR / Aaron Wittenberg, MD / John Eelkema, MD William Romano, MD, FSIR / Vineel Kurli, MD / Gregory Titus, MD
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COMPLAINTS (Briefly describe each complaint by order of severity): HAVE YOU EVER HAD FALLS, AUTO ACCIDENTS OR INJURIES?
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