Today s Date: North Jersey Physical Therapy Medical History Questionnaire Name: Date of Birth: Age: Occupation: Currently working?: How did you hear about our practice: Referring Physician (full name & office location): Primary Care Physician (full name & office location: Reason for your appointment/diagnosis: Date of Onset/Cause: Have you had previous episodes of this condition?: Yes No Date of previous episode: Today my level of pain is: 0 1 2 3 4 5 6 7 8 9 10 (circle one number) least worst Have you received physical therapy for this condition prior to today? Was it helpful? What other treatments have you received for this condition? Were they helpful? Besides pain, do you have numbness? Yes No Tingling? Yes No Weakness? Yes No Where: Current medications: Circle tests you have had to diagnose this condition: X-ray MRI CAT scan EMG Other Results:
North Jersey Physical Therapy Medical History Questionnaire - Page 2 Name: Date: What activities worsen the pain? What decreases the pain? Are you getting: better worse staying the same (circle one) How close to full normal function are you now? 0% 25% 50% 75% 100% What are your goals for physical therapy? Please indicate any of the following conditions you currently have with the letter C and those you have had in the past with the letter P indicating the date. Asthma High Blood Pressure AIDS Hypoglycemia Angina Low Blood Pressure Arthritis Lyme s Disease Bladder/Bowel Disorder Migraine Headaches Cancer Polio Cardiac Condition Respiratory Condition Chronic Infection Seizure Disorder Diabetes Sleep Disorder Hepatitis Thyroid Condition Other Tuberculosis Surgeries(please include procedure and date); Fractures(please include procedure and date):
North Jersey Physical Therapy Numeric Pain Rating Scale and Body Diagram Name: Date: Please mark the figure below by using the following symbols to indicate where your pain is and what kind of pain you are having. Burning: xxxxx Stabbing: >>>>> Aching/Throbbing: ooooo Numbness/Tingling: /////// Please let us know how severe your pain is with "0" being no pain at all while "10" is the worst pain imaginable. Circle the one number that most closely indicates your pain level. Rate your pain at this moment (circle only one number): no pain worst pain 0 1 2 3 4 5 6 7 8 9 10 Rate the least amount of pain you have had in the past 24 hours (circle only one number) no pain worst pain 0 1 2 3 4 5 6 7 8 9 10 Rate the most amount of pain you have had in the past 24 hours (circle one number) no pain worst pain 0 1 2 3 4 5 6 7 8 9 10
North Jersey Physical Therapy Patient - Specific Functional Scale Name: Today's Date Identify up to 5 important activities that you are unable to do or are having moderate to extreme difficulty doing as a result of your pain. For each activity, rate the level of difficulty you have performing each activity using the 0-10 scale listed below. The higher the number, the more easily you can perform the activity. The lower the number, the more difficulty you have. Once you have included activities you are unable to do or are having moderate to extreme difficulty doing, you may also include activities that your are having just a little bit of difficulty doing. Only include these activities if you have not already listed 5 activities you have moderate to extreme difficulty doing. Note: If you are filling this form out at a follow-up appointment, be sure to rate the same activities you listed at your initial appointment. Ask your therapist for a copy of your initial form so that you can rate the same activities. Rating Scale: 0 = unable to perform the activity 10 = able to perform activity at the same level as before 0 1 2 3 4 5 6 7 8 9 10 1. 2. 3. 4. 5. Activity 1st Visit Avg Score Examples: Prolonged sitting/standing, Bending over, Lifting and Carrying, Pushing and Pulling, reaching overhead, Looking up/down, Turning head side to side, Walking time or distance, Running time or distance, Sleeping positions, Walking up/down steps, Reading, Driving, Kneeling, Squatting, Grasping, Chewing, Swallowing, Breathing
North Jersey Physical Therapy Associates, Inc. www.northjerseypt.com 490 Schooley's Mountain Rd, Ste. 3B, Hackettstown, NJ 07840 Phone 908-852-7575; Fax 908-852-9083 95 Madison Ave, Ste 109A, Morristown, NJ 07960 Phone 973-538-8877; Fax 973-538-8873 Assignment of Benefits, Authorizations and Right to Privacy Assignment of Benefits I authorize payment of insurance benefits be made directly to North Jersey Physical Therapy Associates, Inc (NJPTA) for any services rendered to me and/or my dependents by NJPTA. Authorized Representative I hereby appoint NJPTA as my authorized representative with the power to (1) file medical claims with my health plan (2) file reconsiderations, appeals and grievances with my health plan (3) discuss or divulge any of my personal health information or that of my dependents with my health plan. Authorization to Release Information/Consent to Use and Disclose Health Information I understand that this practice maintains health records describing the health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care regarding myself or my dependents. I understand that this information will be used for the purposes of treatment, payment and healthcare operations. Treatment includes the disclosure of health information to other providers who have referred you for services or are involved in your care. Payment includes the disclosure of health information to your insurance company or its administrator so payment can be obtained for services rendered. Health Care Operations include utilization of your records to monitor quality of care given at this practice. I authorize the release of any medical or other information necessary for the purposes stated above. Notice of Privacy Practices I have a right to review or request a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures prior to signing this consent. A copy may be obtained in one of the NJPTA office locations or on their website. I have the right to object to the use of my health information for directory purposes. I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations, and that this organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I wish to have the following restrictions to the use or disclosure of my health information: Name of Patient (Print): Signature of Patient or Parent/Guardian: Date Relationship to Patient:
North Jersey Physical Therapy Associates, Inc. www.northjerseypt.com 490 Schooley's Mountain Rd, Ste. 3B, Hackettstown, NJ 07840 Phone 908-852-7575; Fax 908-852-9083 95 Madison Ave, Ste 109A, Morristown, NJ 07960 Phone 973-538-8877; Fax 973-538-8873 Patient Responsibility Financial Responsibility I understand that I am financially responsible to this organization for any charges not covered by my health insurance plan. It is my responsibility to notify the organization of any changes in my health care coverage. In some cases exact insurance benefits cannot be determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill as determined by the organization and/or my health care insurer if the submitted claims or any part of them are denied for payment. I understand that by signing this form I am accepting financial responsibility as explained above for all payment for professional services received. All deductible payments, co-pays, estimated co-insurance payments, self-pay payments, late cancellation fees, no show fees, and payments for supplies are expected to be paid at the front desk. Out of network insurance payments that are sent directly to you must be brought to the office or mailed to the billing office in Hackettstown within 15 days of receiving the check(s) along with copies of the statements so that we know how to allocate the payments. Missed Appointments and Our Cancellation and No Show Policy We consider it an honor and privilege to be of service to you. In order to maximize the benefit of your treatment, our physical therapy staff provides one-on-one care during treatment sessions reserved especially for you. We do not double book. Missing appointments will impede your progress. Make every effort to attend every scheduled visit according to the treatment plan recommended by your therapist and doctor. You are responsible for your schedule. Make a habit of double-checking your next visit. Note changes to your schedule right away. Not showing up for your appointment or appointments cancelled less than 24 hours in advance affect us all. Available appointments are in high demand and your early cancellation will give another person the possibility to have the treatment they need. Due to decreases in in-network health insurance payments, rising costs including dry needling costs which are currently administered for free (Most insurances do not pay for dry needling.), increased paperwork and statistics reporting required by insurances, and a rising demand for our specialties have forced us to implement a harsher late cancellation and no show fee of $60.00 per missed visit beginning January 1, 2015. Although we do understand that there may be extenuating circumstances, cancellations less than 24 hours or not showing up for your appointment for any reason will result in a $60.00 fee beginning January 1, 2015 Name of Patient (print): Signature of Patient or Parent/Guardian: Date Relationship to Patient:
North Jersey Physical Therapy Associates, Inc. www.northjerseypt.com 490 Schooley's Mountain Rd, Ste. 3B, Hackettstown, NJ 07840 Phone 908-852-7575; Fax 908-852-9083 95 Madison Ave, Ste 109A, Morristown, NJ 07960 Phone 973-538-8877; Fax 973-538-8873 Informed Consent for Dry Needling of Trigger Points Patient s Name: Date: Physical Therapist: Your physical therapist has recommended that you receive Dry Needling technique for the evaluation and or treatment of myofascial trigger points and tender points within your muscles, tendons or ligaments. Recent evidence has shown that trigger points are localized areas of hyperactive muscle or tissue that have numerous inflammatory and pain producing chemicals causing local tightness of the muscle. The tightness of the muscle is often accompanied by pain and dysfunction of the muscle, consequently irritating local nerve endings as well as decreasing normal movement of the nearby joints enough to limits normal functional activities. Dry needling to trigger points has been shown to decrease or completely reduce the irritation and to reduce or completely eliminate the irritating chemicals in an active trigger point. This release can immediately improve range of motion, decrease pain and improve function. Patients often feel a significant improvement of their symptoms immediately after the treatment. Trigger point dry needling facilitates a hastened return to strengthening and exercises that result in a faster return to function. The dry needling procedure involves placing a very thin, single use disposable sterile solid tilament needle (not hollow) with sterile technique into a trigger point. The number of needles used during any individual visit and the number of visits you are given this treatment depends on many factors that differ from patient to patient. THIS IS NOT ACUPUNCTURE; NOR IS THIS ANY FORM OF ACUPUNCTURE. Be assured that this procedure is very safe. Most patients do not feel the needle when it is placed and other than a focal muscle twitch or feeling of a subtle muscle cramp around the needle tip, there is little to no pain with this procedure. Because the needle being used is very thin, there is usually little to no bleeding with this procedure. Occasionally, however, complications may arise. Any procedure intended to help may have complications or side effects. While the chances of experiencing complications are unlikely, it is the practice of this clinic to inform our patients about them. Most of these complications are very minor and self-limiting and resolve rapidly.
Informed Consent for Dry Needling of Trigger Points Page 2 Minor complications include: Focal bruising at the needle insertion site. Minor soreness in the immediate area afterword. A small amount of bleeding at the needle insertion site that stops on its own within a few minutes. These minor complications generally resolve within a day or two after the treatment. More serious complications, while very rare, are possible and include: Fainting Persistent bleeding at the needle insertion site. Infection Puncture of the lung (only if the needle is being used near lung tissue). The possibility of complications may be increased if you have certain pre-existing problems. It is very important that you discuss with your physical therapist any problems that you have had, currently have, or might have, specifically: I have a fear of needles, have fainted, or fear I will faint when needles have been used for my diagnosis or care in the past. I have a bleeding disorder that causes my blood to clot slowly or not at all. Please specify: I have a history of a blood disorder that can be transmitted to another person. Please specify: I take blood thinners (anti-coagulation) medication. Please specify: I have taken pain relievers (e.g. aspirin, Tylenol, Ibuprofen, etc.) in the past 48 hours. Please specify: I have read this Patient Information and Consent carefully, I understand this procedure is not acupuncture and I have had an opportunity to ask questions and obtain any desired clarification. I also understand that there is no guarantee or warranty for a specific cure or result. I understand the above statements regarding examination and treatment side effects. I give my permission and consent to the procedure or treatment. I understand that I can stop this procedure at any time. Patient Signature: Date: If patient is less than 18 years of age a parent or legal guardian must sign. Name of Parent/Legal Guardian (Please print): Signature: Date: