Peterson Physical Therapy Registration Form Last Name: First Name: Date: Name of parent/guardian (if patient is a minor) Mailing Address: City/State/Zip: Date of Birth: Home Phone: Email: Cell Phone: Cell Carrier for Text Reminders: Have you received Physical Therapy in the last 12 months? Employer Name, Address, Phone: Insurance Provider: Insurance Phone: Member ID: Primary Insurance Information (Please give insurance card to the front desk) Insurance Address: Employer: Group Number Subscriber Name (if different than above): Subscriber DOB: HMO? PPO? Patient's relationship to Subscriber: Self Spouse Child Other Secondary Insurance Information (Please give insurance card to the front desk) Insurance Provider: Insurance Address: Insurance Phone: Member ID: Subscriber Name (if different than above): Subscriber DOB: Employer: Group Number HMO? PPO? Patient's relationship to Subscriber: Self Spouse Child Other Name: Home Phone: Referring Physician & Phone Number: Emergency Contact Relationship: Cell Phone: Physician Information Primary Care Physician & Phone Number:
Name: History of current condition/complaint and mechanism of injury if known: Have you had any falls in the past year? Y/N If yes injury due to fall? Please list all previous injuries, accidents, surgeries or any other pertinent information regarding treatments received: Please list special tests you have received for this condition (ie: X-rays, MRI, CT Scan etc ) How would you describe your overall health at the present time Excellent? Very Good? Fair? Poor? Please Circle any condition that you have ever had: Pleurisy Diabetes Mumps Polio Epilepsy Influenza/TB Please Circle any of the following you have had in the past year: Chicken Pox Whooping Cough Cancer Rheumatic Fever Poor Appetite Liver Problems Abdominal Cramps Heart Problems *Arrhythmia *PACEMAKER *High/Low Blood Pressure *Angina *CHF Bladder Problems Stroke/TIA Allergies Dental Problems Sleep Disturbance Psoriasis/ Eczema Menstrual Irregularity Breast Lumps Excessive Thirst Nausea Gall Bladder Painful Urination Congestion Vision Problems Ear Aches Prostate Dysfunction Vomiting Diarrhea Weight Loss/Gain Frequent Urination Lung Problems * Shortness of Breath *COPD *Asthma *Pneumonia Fatigue Sexual Dysfunction HIV/AIDS Positive Constipation Hemorrhoids Heartburn Discolored Urine Varicose Veins TMJ Breast Pain Vaginal Infection Headaches High Cholesterol Medication List: If you need more space for medications please write on the back of this form or you may provide your own list. Medication Reason Dosage I, the undersigned, attest that the above health information is factual to the best of my knowledge. Patient/Guardian Signature: Date:
Welcome and Thank You for choosing Peterson Physical Therapy for your Physical Therapy needs. We understand that illness and emergencies happen. As a courtesy to our staff and to other clients trying to be scheduled, we require a 24 hour or greater notice for cancellations. We also understand that this isn t always possible. It is up to the discretion of your therapist and based on your attendance history whether or not a no show fee of $50 will be assessed for a missed visit. Medical Information Release Authorization and Privacy Policy I,, authorize the release of any medical information required in the processing of applications for financial coverage for services rendered on this date and all subsequent dates while under the care of Peterson Physical Therapy, LLC. I have authorized direct payment of medical benefits on my behalf to Peterson Physical Therapy, LLC. I understand that I am personally responsible for charges not covered by this assignment at the time of treatment such as copay, coinsurance, and deductible charges. I may be asked to make advanced payment toward my deductible at the time of service. I understand that if I refuse I am then still responsible for full payment once all services are complete. This assignment shall be in effect for this date and all subsequent dates while under the care of Peterson Physical Therapy, LLC. PRIVACY POLICY I understand that Peterson Physical Therapy, LLC will maintain my privacy to the highest of standards and may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services and any administrative operations related to treatment or payment. I have read and completely understand the above written statements. Please Print Your Name Date Patient/Guardian Signature
Peterson Physical Therapy is a hands-on Physical Therapy clinic. Treatment consists of manual therapy techniques including bone and soft tissue mobilizations and manipulations and trigger point dry needling (TDM) as well as neuromuscular re-education, prescriptive therapeutic exercise, gait training, and functional activities. Some forms of treatment may require deep pressure and cause some transient soreness or even bruising. This is not unusual and is rarely a concern but you are encouraged to contact your clinician with any questions or concerns. The number of treatments needed and the recovery time can vary due to age of injury, repetitive nature of the injury, patient s lifestyle and co-morbidities, and the patient s age as well as other contributing factors. Response to treatment varies from person to person therefore constant assessment and reassessment of the client is necessary for efficient treatment strategy and planning. It is your right to decline any part of your treatment at any time before or during the treatment session. It is your right to ask your Physical Therapist about the treatment they have planned based on your individual history, diagnosis, symptoms, and examination. Consequently, it is your right to discuss the potential risks and benefits involved in your treatment. Be advised that should your therapist suggest Trigger Point Dry Needling (TDN) as a part of your treatment plan you must also sign a separate consent form outlining the risks associated with that treatment modality if you agree to the plan. I have read and fully understand the above statements. I understand the nature of the treatments at Peterson Physical Therapy, LLC. I authorize Chris Peterson, MPT, MBA and Susan Peterson, MPT, DPT to use treatment techniques as deemed necessary and within the State of Maryland Physical Therapy Practice Act for my safe and effective recovery. I have read and completely understand the above written statements. Please Print Your Name Date Signature of Patient/Guardian
TDN involves placing a small needle into the muscle at the trigger point. This is typically in an area where the muscle is tight and may be tender. The needle is introduced with the intent of causing the muscle to contract and then release, improving the flexibility of the muscle and therefore decreasing the symptoms. The performing therapist will not stimulate any distal or auricular points during the dry needling treatment. TDN is a valuable treatment for musculoskeletal related pain such as soft tissue and joint paint, as well as to increase muscle performance. Like any treatment there are possible complications. While these complications are rare in occurrence, it is recommended you read through the possible risks prior to giving consent to treatment. Risks of the procedure: Though unlikely, there are risks associated with this treatment. The most serious risk associated with TDN is accidental puncture of a lung (pneumothorax). If this were to occur, it may likely only require a chest x-ray and no further treatment as it can resolve on its own. The symptoms of pain and shortness of breath may last for several days to weeks. A more severe lung puncture can require hospitalization and re-inflation of the lung. This is a rare complication and in skilled hands should not be a concern. If you feel any related symptoms, immediately contact your IMT / TDN provider. If a pneumothorax is suspected you should seek medical attention from your physician or, if necessary, go to the emergency room. Other risks may include bruising, infection and nerve injury. Please notify your provider if you have any conditions that can be transferred by blood, require blood anticoagulants or any other conditions that may have an adverse effect to needle punctures. Bruising is a common occurrence and should not be a concern unless you are taking a blood thinner. As the needles are very small and do not have a cutting edge, the likelihood of any significant tissue trauma from IMT / TDN is unlikely. Please consult with your practitioner if you have any questions regarding the treatment above. Do you have any known disease or infection that can be transmitted through bodily Fluids? Yes NO Are you currently pregnant? Y/N Date of last Period: If you marked yes to either of the above questions, please discuss further with your practitioner. Your signature below indicates that all questions and concerns regarding treatment with dry needling have been addressed to your satisfaction and you consent to the use of dry needling as part of your treatment plan. Please print your name Date Signature