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Kinetic Energy PT New Patient Information Patient Name: Billing/Mailing Address (If not already provided online): City: State: Zip: Social Security #(Only required if used as identifier for insurance company): Referring Physician: Diagnosis: Date of Onset (injury, accident, surgery date or recent date symptom started): Check here if you do not want to receive KEPT s quarterly newsletter via email Policy Holder Information (person financially responsible if not already provided above) Name: Relationship to patient: Birth date: Sex: Social Security #: Mailing Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Insurance Information (To be completed by authorized Kinetic Energy PT employee: initial ) Company:_ Phone: Address: City: State: Zip: Claim / Group # Policy or ID #: Co Pay: Deductable: MET? Y or N Referral Required? Y or N Pre Auth Required? Y or N Coverage Details: Insurance Verifier Name: Date: Time: Secondary Insurance: Phone: Policy # or ID: Coverage Details:

NOTICE OF PATIENT INFORMATION PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO INFORMATION. PLEASE REVIEW IT CAREFULLY. Kinetic Energy Physical Therapy PC s LEGAL DUTY Kinetic Energy Physical Therapy PC 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. USE AND DISCLOSURES OF HEALTH INFORMATION Kinetic Energy Physical Therapy PC uses your personal health information primarily for treatment; obtaining payment for treatment; conducting internal administrative activities and evaluating the quality of care that we provide. For example, Kinetic Energy Physical Therapy PC 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. Kinetic Energy Physical Therapy PC may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, for research studies and for emergencies. We also provide information when required by law. In any other situation, Kinetic Energy Physical Therapy PC s policy is to obtain your written authorization before disclosing your personal health information. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization to stop future disclosures at any time. Kinetic Energy Physical Therapy PC may change its policy at any time. When changes are made, a new Notice of Information Practices will be posted in the waiting room and patient exam areas and will be provided to you on your next visit. You may also request an updated copy of our Notice of Information Practices at any time. PATIENT S INDIVIDUAL RIGHTS You have the right to review or obtain a copy of your personal health information at any time. You have the right to request that we correct any inaccurate or incomplete information in your records. You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment or other related administrative purposes. You may also request in writing that we not use or disclose your personal health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances. Kinetic Energy Physical Therapy PC will consider all such requests on a case by case basis, but the practice is not legally required to accept them. CONCERNS AND COMPLAINTS If you are concerned that Kinetic Energy Physical Therapy PC may have violated your privacy rights or if you disagree with any decision we have made regarding access or disclosure of your personal health information, please contact our practice manager at the address listed below. You may also send a written complaint to the US Department of Health and Human Services. For further information on Kinetic Energy Physical Therapy PC s health information practices or if you have a complaint, please contact the following person: Kinetic Energy Physical Therapy PC Nicole P Rabanal PT, CSCS PO Box 883299, Steamboat Springs, CO 80488 Telephone: 970-879-8026 or Fax: 970-879-8046 I have read and fully understand Kinetic Energy Physical Therapy PC s Notice of Information Practices. I understand that Kinetic Energy Physical Therapy PC may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluation the quality of services provided and any administrative operations related to treatment or payment. I understand I have the right to designate individuals to whom my information can be released. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations of I notify the practice. I also understand that Kinetic Energy Physical Therapy PC will consider requests for restriction on a case my case basis, but does not have to agree to requests for restrictions. I hereby consent to the use and disclosure of my personal health information for purposes as noted in Kinetic Energy Physical Therapy PC s Notice of Information practices. I understand that I retain the right ot revoke this consent by notifying the practice in writing at any time. Initials

Musculoskeletal Pain Diagram Name: Date: Age: Gender: Occupation: Hobbies/Sports Current Symptoms: 1) Where are you currently experiencing symptoms? 2) What date (roughly) did the symptoms begin? 3) Did your pain begin Gradually? Suddenly? By Injury? Explain: 4) Have you had this problem before? YES NO If yes, when? 5) What aggravates your symptoms? Sitting Rise from Sitting Standing Lying Down Lifting Overhead Activity Bending Walking Running Stairs Squatting Kneeling Jumping Coughing/Sneezing Other: 6) What eases your symptoms? 7) My goal for physical therapy is: 8) Please circle any treatments you think may help you: Stretching/Strengthening Heat/Ice Dry Needling (similar to accupuncture) Joint manipulation/ popping Massage Electrical Stimulation Other Please rate your pain over the last 24 hours: 0 1 2 3 4 5 6 7 8 9 10 No Pain Worst Pain Please rate your pain at it s best: 0 1 2 3 4 5 6 7 8 9 10 No Pain Worst Pain Please rate your pain at it s worst: 0 1 2 3 4 5 6 7 8 9 10 No Pain Worst Pain Please draw your areas of complaint using the diagram and the markings below: ACHE BURNING NUMBNESS PINS/NEEDLES THROBBING OTHER/GENERAL ^^^^^ ======== 0000000000.. //////////////////// xxxxxxxxxxxxxxx

Name: Height Weight Have you or an immediate family member been diagnosed with any of the following: Self Family Cancer Diabetes High Blood Pressure Heart Disease Lung Disease Angina/Chest Pain Stroke Osteoporosis/Osteopenia Arthritis Allergies/Asthma Kidney/Urinary Disease Sexually Transmitted Disease Seizures Rheumatoid Arthritis Depression Blood Clots Blood Borne disease Bleeding Disorder Abnormal Cholesterol Have you recently had, or are you currently experiencing any of the following: A change in your health Nausea, Vomiting, or Diarrhea Fever/Chills/Sweats Unexplained weight change Numbness or tingling Changes in appetite Difficulty swallowing Bowel/bladder changes Difficulty breathing Dizziness/fainting Infection Change in your balance Pain at night Excessive Fatigue/shortness of breath Incontinence Rashes or skin irregularity Headache Difficulty with hearing/vision/speech Use of steroid medications Swelling of ankles Do you or have you smoked tobacco? If yes, Packs Years. Last used. Do you drink alcoholic beverages? If yes, how many drinks per week? During the past month: Have you often been bothered by little interest or pleasure in doing things?...yes..no Have you often been bothered by feeling down, depressed or hopeless?...yes..no Are you pregnant? Estimated Delivery Date Are your symptoms: (check one) Worsening The same Improving Do you consider yourself under stress? Yes No My symptoms are WORST in the: Morning Afternoon Evening Night After Activity N/A My symptoms are BEST in the: Morning Afternoon Evening Night After Activity N/A Describe your exercise level in the last 3 months: Strenous min/day days/week Moderate min/day days/week Light min/day days/week Please list current medications you are taking: Please describe any other health conditions you may have (Including previous surgery):

NECK PAIN DISABILITY INDEX QUESTIONNAIRE PLEASE READ: This questionnaire is designed to enable us to understand how much your neck pain has affected your ability to manage your everyday activities. Please answer each section by circling the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate to you, but PLEASE JUST CIRCLE THE ONE. CHOICE WHICH MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW. SECTION 1 - Pain Intensity SECTION 6 - Concentration A I have no pain at the moment. B The pain is very mild at the moment. C The pain is moderate at the moment. D The pain is fairly severe at the moment. E The pain is very severe at the moment. F The pain is the worst imaginable at the moment. SECTION 2 -Personal Care (Washing, Dressing, etc.) A I can look after myself normally without causing extra pain. B I can look after myself normally, but it causes extra pain. C It is painful to look after myself and I am slow and careful. D I need some help, but manage most of my personal care. E I need help every day in most aspects of self care. F I do not get dressed, I wash with difficulty and stay in bed. SECTION 3 - Lifting A I can lift heavy weights without extra pain. B I can lift heavy weights, but it gives extra pain. C Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, for example, on a table. D Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned. E I can lift very light weights. F I cannot lift or carry anything at all. SECTION 4 - Reading A I can concentrate fully when I want to with no difficulty. B I can concentrate fully when I want to with slight difficulty. C I have a fair degree of difficulty in concentrating when I want to. D I have a lot of difficulty in concentrating when I want to. E I have a great deal of difficulty in concentrating when I want to. F I cannot concentrate at all. SECTION 7 - Work A I can do as much work as I want to. B I can only do my usual work, but no more. C I can do most of my usual work, but no more. D I cannot do my usual work. E I can hardly do any work at all. F I cannot do any work at all. SECTION 8 - Driving A I can drive my car without any neck pain. B I can drive my car as long as I want with slight pain in my neck. C I can drive my car as long as I want with moderate pain in my neck. D I cannot drive my car as long as I want because of moderate pain in my neck. E I can hardly drive at all because of severe pain in my neck. F I cannot drive my car at all. SECTION 9 - Sleeping A I can read as much as I want to with no pain in my neck. B I can read as much as I want to with slight pain in my neck. C I can read as much as I want to with moderate pain in my neck. D I cannot read as much as I want because of moderate pain in my neck. E I cannot read as much as I want because of severe pain in my neck. F I cannot read at all. SECTION 5 - Headaches A I have no headaches at all. B I have slight headaches which come infrequently. C I have moderate headaches which come infrequently. D I have moderate headaches which come frequently. E I have severe headaches which come frequently. F I have headaches almost all the time. A I have no trouble sleeping. B My sleep is slightly disturbed (less than 1 hour sleepless). C My sleep is mildly disturbed (1-2 hours sleepless). D My sleep is moderately disturbed (2-3 hours sleepless). E My sleep is greatly disturbed (3-5 hours sleepless). F My sleep is completely disturbed (5-7 hours) SECTION 10 - Recreation A I am able to engage in all of my recreational activities with no neck pain at all. B I am able to engage in all of my recreational activities with some pain in my neck. C I am able to engage in most, but not all of my recreational activities because of pain in my neck. D I am able to engage in a few of my recreational activities because of pain in my neck. E I can hardly do any recreational activities because of pain in my neck. F I cannot do any recreational activities at all. COMMENTS: NAME: DATE: SCORE:

Name: Date: mm dd yy Here are some of the things other patients have told us about their pain. For each statement please circle the number from 0 to 6 to indicate how much physical activity such as bending, lifting, walking or driving affect or would affect your pain. Completely Unsure Completely Disagree Agree 1. My pain was caused by physical activity. 0 1 2 3 4 5 6 2. Physical activity makes my pain worse. 0 1 2 3 4 5 6 3. Physical activity might harm my pain area. 0 1 2 3 4 5 6 4. I should not do physical activities which 0 1 2 3 4 5 6 (might) make my pain worse. 5. I cannot do physical activities which 0 1 2 3 4 5 6 (might) make my pain worse. The following statements are about how your normal work affects or would affect your pain. Completely Unsure Completely Disagree Agree 6. My pain was caused by my work or by an 0 1 2 3 4 5 6 accident at work. 7. My work aggravated my pain. 0 1 2 3 4 5 6 8. I have a claim for compensation for my 0 1 2 3 4 5 6 pain. 9. My work is too heavy for me. 0 1 2 3 4 5 6 10. My work makes or would make my pain 0 1 2 3 4 5 6 worse. 11. My work might harm my injury. 0 1 2 3 4 5 6 12. I should not do my regular work with my 0 1 2 3 4 5 6 present pain. 13. I cannot do my normal work with my 0 1 2 3 4 5 6 present pain. 14. I cannot do my normal work until my pain 0 1 2 3 4 5 6 is treated. 15. I do not think that I will be back to my 0 1 2 3 4 5 6 normal work within 3 months. 16. I do not think that I will ever be able to go 0 1 2 3 4 5 6 back to that work.

Patient Financial Responsibilities Thank you for choosing Kinetic Energy Physical Therapy. We consider it a privilege to provide your physical therapy care. From the moment you walk in the door until the time we regrettably have to say our goodbyes, we are committed to providing you with amazing service throughout your experience with us. In order to do so, we would like to offer the following information: INSURANCE We need accurate information about your insurance. Therefore, please have your current insurance card with you at all times. Please report any changes to your insurance coverage, demographics, etc. to us as soon as possible. Kinetic Energy PT will verify your benefits and eligibility with your insurance company; we recommend that you do the same. All benefits are subject to medical necessity and do not represent a guarantee of payment by your insurance company. CO PAYS We are required by our insurance contracts to collect all co pay amounts at the time of service. We accept cash, check, Visa, and MasterCard. If you would like to limit the number of transactions, we do accept payment for the week in advance. COINSURANCE Coinsurance is an estimated percentage of an eligible expense that you are required to pay for a covered service. These details are specific to your individual plan; please call your insurance company for details. DEDUCTIBLES If you have not met your deductible we will arrange for payment with you after it is processed through your insurance company. Please note that other healthcare provider services are typically applied towards this deductable as well. SELF PAY PATIENTS We are delighted to extend a 25% cash courtesy discount to patients electing to self pay at the time of service. Special payment arrangements can be made as needed at your initial visit if there is a financial hardship situation. Medicare A physician s referral is required specifying the duration and frequency for physical therapy every 90 days. Maximum coverage is a combined benefit of $1870.00/year for physical and speech therapies. Secondary coverage may help to cover additional costs (please call your secondary insurance company for details). STATEMENTS Statements are sent monthly to the address provided. In the event of default, you will be referred to an outside agency for purposes of collection of unpaid balance. No Show Policy You, as a patient at Kinetic Energy PT, are personally responsible for your appointments. We reserve the right, at our discretion, to charge a $40 No Show fee which is not billable to your insurance company. We greatly appreciate a 24 hour advanced notice for any cancellations.

Consent to Physical Therapy 1. I have presented myself to this facility for physical therapy treatment and consent to diagnostic procedures and care provided by my attending physical therapist. 2. I understand that information from my medical record(s) kept by this facility may be used for educational administrative and/or facility approved purposes when my personal identity will not be revealed. 3. I hereby authorize the release of medical information necessary to process my insurance and authorize payment directly to the provider of services. I am responsible for any services not covered by this authorization. I have read and fully understand the patient financial responsibilities form. I HAVE READ AND FULLY UNDERSTAND THE ABOVE GENERAL CONSENT FORM AND ANY QUESTIONS HAVE BEEN ANSWERED TO MY SATISFACTION. Signature of Patient (or parent if patient is a minor under 18) Date Witness (authorized signature of Kinetic Energy PT employee) Date Intramuscular Manual Therapy aka Trigger Point Dry Needling (TDN) Consent During your time with us we may recommend a specialized form of treatment referred to as trigger point dry needling (TDN), and the State of Colorado requires us to obtain specific consent to perform this treatment. TDN involves placing a small needle into a tight or tender muscle with the intent of causing the muscle to contract and then release, which helps to improve the flexibility of the muscle and decrease pain. This treatment does not stimulate distal or auricular points, as is done in acupuncture. While serious complications from TDN are rare in occurrence, it is recommended you read through the possible risks prior to giving consent to treatment. The risks of TDN include: COMMON (1-10%): muscle soreness, bruising, minor bleeding RARE (.1-1%): fainting, headache SERIOUS (.05 per 10,000 treatments): Pneumothorax Nicole Rabanal, PT, CSCS has completed 93 hours of training in this procedure fully meeting the requirements of the State of Colorado to perform TDN. Finn Gerstell, DPT has completed a Level 1 course and according to the State of Colorado is allowed to perform TDN clinically in order to complete his course of study. (initial) I consent to the use of TDN treatment if recommended by my attending physical therapist (we will thoroughly review the benefits, risks, and benefits prior to any treatment).

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