Physical Therapy Prescription (dated no longer than 30 days prior to Initial Evaluation with the therapist)
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- Elizabeth Richards
- 5 years ago
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Transcription
1 Pre Evaluation Checklist The following items need to be completed and returned to Onsite Physical Therapy two days prior to your scheduled Initial Evaluation. You can come by the fitness center anytime during normal business hours to fill these out and get your insurance cards copied. Please call (561) with any insurance coverage questions, as we may be out of your network. Thank you! We look forward to working with you! Physical Therapy Prescription (dated no longer than 30 days prior to Initial Evaluation with the therapist) Insurance Cards & Photo ID copied: (including front and back of Secondary insurance card) Patient Registration form filled out & signed Health History form filled out COMPLETELY (including medications you are taking) HIPAA rights form Signed ABN Signed (Medicare only, if you have had prior PT this year) Cancellation Policy Signed
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3 HEALTH HISTORY FORM Name: Height/weight: Date: Please circle those conditions which you have now or have had in the past: Frequent Falls Osteoarthritis Rheumatoid Arthritis Cancer Cardiac Problems Metal Implants (i.e. pins/plates) Prosthesis Asthma Pregnancy (current) Previous Accidents Sleep Dysfunction Hepatitis/AIDS Osteoporosis Seizure Disorder Epilepsy Angina High Blood Pressure Diabetes: Type I or II Emphysema Anxiety or Panic Disorders Stroke/TIA Headaches Depression Heart Attack (myocardial infarction) Hearing impairment/hoh/hearing Aides Peripheral Vascular Disease (or claudication) Neurologic Disorders (MS/Parkinson s) Blood Clot/Thrombosis/Embolism/DVT Visual Impairment (such as cataracts, glaucoma, macular degeneration) Back Pain (neck pain, low back pain, degenerative disc disease, spinal stenosis) Kidney, Bladder, Prostate, incontinence or urination problems Gastrointestinal disease, ulcer, hernia, reflux, bowel, liver, gall bladder problems Allergies: Please list: Other Important Conditions/Disorders: Please list: Prior surgeries: List any Medications and DOSAGE that you are currently taking: When I DO NOT take pain medication my pain level is: No pain Worst pain possible (circle one) List previous rehabilitation or medical treatment for this condition: Dr. /Therapist Month/Year Elimination of Symptoms (circle one): Full Partial None Full Partial None
4 PLEASE LIST ALL MEDICATIONS MEDICATION DOSAGE MEDICAL ISSUE
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7 On-Site Physical Therapy, LLC No-Show / Cancellation Policy Please Read Carefully We realize that emergencies and other scheduling conflicts arise and are sometimes unavoidable, however, advance notification allows us to fulfill other patient s scheduling needs and keeps the clinic operating at its most efficient level. Due to our one-on-one 60-minute treatments, missed appointments are a significant inconvenience to your physical therapy, the clinic and other patients. In addition, Medicare requires that you have at least 2 visits per week. Unless otherwise stated by your therapist, you must make every effort to make and keep your scheduled appointment due to the possibility of Medicare not reimbursing Onsite PT for your care and you being charged. 1. Please provide our office with 24-hour notice to change or cancel an appointment. Patients who do not attend a scheduled appointment or do not provide 24-hour notice to change a scheduled appointment may be responsible for a $75.00 office visit charge, check or cash payable to On-site Physical Therapy LLC. This charge cannot be billed to insurance and must be paid on or before the next scheduled appointment. Cancellations due to sickness or family emergencies will be omitted. 2. Please DO NOT CANCEL if you are feeling worse and believe the treatment is not working. Keep your appointment and discuss any changes with your therapist. Please understand that your pain will probably fluctuate as your course of treatment progresses. 3. Please DO NOT CANCEL if you are feeling better. Keep your appointment in order to progress your plan and prepare for discharge. Thank you for providing our office and our patients with this courtesy. Signing below indicates you understand and agree to the terms of this policy. Signature of Patient Date Signature of Responsible Party (if applicable) Date
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Which physician are you scheduled to see? Scheduled Appointment Date: As a reminder: Please arrive minutes prior to your scheduled appointment.
Which physician are you scheduled to see? Scheduled Appointment : As a reminder: Please arrive 15-20 minutes prior to your scheduled appointment. Please bring the following on the day of your scheduled
NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW- UP NEUROLOGY QUESTIONNAIRE
Neurology East 48 Medical Park Dr. East Richard G. Diethelm, MD Suite 351 Andrea Sutton, RN, MSN, ANP- BC Birmingham, AL 35235 (205) 836-9366 www.neurologyeast.com NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW-
ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
NAME: ABOUT YOU WHO REFERRED YOU TO OUR OFFICE? CHIROPRACTIC EXPERIENCE ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: CELL PHONE: How did you hear about our office? NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT
Patient Name (First, Middle, Last) Height Weight. Ethnicity Race Language. Address. City State Zip. Home Phone Cell Phone. Work Phone Other Phone
Patient Name (First, Middle, Last) Height Weight Date of Birth Social Security # Gender Male Female Ethnicity Race Language Address City State Zip Home Phone Cell Phone Work Phone Other Phone Email Occupation
Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
![Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No](/thumbs/89/99616722.jpg "Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No")
Patient Information Welcome Who is responsible for this account? SSN Relationship to Patient Patient Name Insurance Co. Name: Preferred First Name Group #: ID #: Sex [ ] M [ ] F Age: Birthdate SS# Birthdate
Hamilton Back Clinic
Hamilton Back Clinic Intake Form Name: City: Address: Postal Code: Phone: Sex: M F Date of Birth: Month/Day/Year E mail: Emergency Contact: Name/Phone: Name of Family Physician (MD): Employer: Employer
Dr. Amelia Croll, Naturopathic Doctor Living Science Wellness Centre 59 Iber Rd Unit 25 Stittsville, ON K2S 1E7 (613)
Dr. Amelia Croll, Naturopathic Doctor Living Science Wellness Centre 59 Iber Rd Unit 25 Stittsville, ON K2S 1E7 (613)836-7901 Personal Information Intake Form Date: Name: Sex: M F Age: Birth Date: Address: