Download Adult Intake Forms - Horizon Therapy Services

PATIENT INTAKE
FIRST NAME: ________________________________ MI____________
LAST NAME_________________________________
DATE OF INJURY/ONSET: __________________ TODAYS DATE_________________
DATE OF BIRTH__________________________ AGE____________ SEX: [ ] MALE
[ ] FEMALE
STREET ADDRESS: __________________________________________ CITY: ____________________________ STATE: _______ ZIP CODE:___________
HOME PHONE: _______________________WORK PHONE ____________________ CELL PHONE:______________________________________
SOCIAL SECURITY #: ____________________________________
INJURY AREA__________________ INJURY RELATED ___AUTO___WORK__OTHER__
PARENT OR LEGAL GUARDIAN IF MINOR:
PARENT /LEGAL GUARDIAN NAME: __________________________________________________________ DATE OF BIRTH:__________________________
SOCIAL SECURITY #: ____________________________________________ RELATION: ____________________________________________________
HOME PHONE: _________________________________________ CELL PHONE: _____________________________________
EMPLOYMENT INFORMATION - PATIENT / PARENT OR LEGAL GUARDIAN EMPLOYER INFORMATION
EMPLOYER : ____________________________________________________________ TELEPHONE NUMBER : _____________________________________
BUSINESS ADDRESS: ____________________________________________________ CITY:_______________________STATE_________ ZIP CODE ___________
OCCUPATION: ______________________________________________CONTACT AT EMPLOYER____________________________________________________
EMERGENCY CONTACT:
NAME: __________________________________________________________
DAYTIME PHONE NUMBER___________________________________________
REFERRING PHYSICIAN___________________________________________ PHONE NUMBER__________________________________________________
DATE OF SURGERY:
DATE OF CAST REMOVAL:
INSURANCE INFORMATION
PRIMARY INSURANCE___________________________________________ INSURED NAME____________________________________________________
GROUP#_________________ID#____________________________________ ADDRESS________________________________CITY______________________
INSURED EMPLOYER___________________________________________STATE_______ZIP_______________________PHONE_______________________
RELATIONSHIP TO INSURED___________________________INSURED DATE OF BIRTH_________________ INSURED SEX: [ ] MALE
[ ] FEMALE
SECONDARY INSURANCE___________________________________________ INSURED NAME_________________________________________________
GROUP#_________________ID#____________________________________ ADDRESS________________________________CITY_____________________
INSURED EMPLOYER___________________________________________STATE_______ZIP_______________________PHONE_______________________
RELATIONSHIP TO INSURED___________________________INSURED DATE OF BIRTH_________________ INSURED SEX: [ ] MALE
ARE YOU RECEIVING OR HAVE YOU RECENTLY RECEIVED HOME HEALTH SERVICES?
[ ] YES
[ ] NO
ARE YOU RECEIVING OR HAVE YOU RECENTLY RECEIVED OTHER THERAPY SERVICES?
[ ] YES
[ ] NO
[ ] FEMALE
I certify that the information provided by me is correct. I will notify you of any changes in my status or to
the above information.
Date: ___________________________________ Signature: ________________________________________
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CONSENT FORM
CONSENT TO TREATMENT: I consent to rehabilitation and related services at Horizon Therapy Services. Also in doing so, to
perform any procedure that in their judgment may be advisable to therapeutically remedy conditions discovered during the
above procedures. I understand there are risks involved in any procedure or treatment and it is not possible to guarantee or give
assurance of a successful result.
PLEASE INITIAL_______________________
TREATMENT OF MINORS: I, as parent/guardian of a minor receiving treatment hereunder, do hereby agree and understand
that I may be advised to remain on the premises during any such treatment, and waive any claim I may have resulting from
failure to do so.
PLEASE INITIAL_______________________
LIABILITY: I know and agree that Horizon Therapy Services is not responsible for loss or damage to personal valuables.
PLEASE INITIAL_______________________
WAIVER AND RELEASE: I hereby release, discharge and acquit Horizon Therapy Services, it’s agents, representatives,
affiliates, employees, or assigns, of and from any and all liability, claim, demand, damage, cause of action, or loss of any kind
arising out of or resulting from my refusal to accept, receive or allow emergency and or medical services, including but not
limited to ambulance service, Emergency Medical Technician, physician or urgent care services.
PLEASE INITIAL_______________________
AUTHORIZATION OF PAYMENT: I hereby assign all benefits directly to Horizon Therapy Services. This is a direct
assignment of my rights and benefits under this policy. I also authorize release of any medical records necessary to facilitate my
treatments and to process the medical claims associated with such, as otherwise permitted or required in the Notice of Privacy
Practices.
Solely as a courtesy to you we will bill your insurance carrier. You are responsible for the entire bill when services are rendered.
If your insurance carrier does not remit payment within 60 days, the balance will be due in full from you. In the event that your
insurance company requests a refund of payment made, you will be responsible for the amount of money refunded to your
insurance company. In the event your insurance company establishes an internal usual and customary fee schedule, you will be
responsible for the difference remaining. There is a FINANCE CHARGE computed at the rate of 1% per month or an Annual
Percentage Rate of twelve percent.
If any payment is made directly to your for services billed by us, you must recognize and obligation to promptly remit same to
Horizon Therapy Services.
If at any time during your treatment here you should change employment or insurance carrier PLEASE NOTIFY US AT
ONCE.
I understand and agree that if I fail to make any of the payments for which I am responsible in a timely manner, I will be
responsible for all costs of collecting monies owed, including court costs, collection agency fees and attorney fees.
Estimated coverage information is provided as a courtesy to our patients, but is not intended to release them from total
responsibility for their account balance.
PLEASE INITIAL_______________________
The above does not apply for those patients that are considered Worker’s Compensation.
However, be advised if you claim Work Comp benefits and are denied such benefits, you will be
held responsible for the total amount of charges for services rendered to you. (Please initial if
this applies to you. __________)
Signature: _____________________________________ Date: ___________________
(Patient /Parent or Legal Guardian)
Patient Name: _______________________________________
(Please Print)
Witness: ____________________
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PATIENT HEALTH QUESTIONNAIRE
Name: _________________________________Date of Birth: _____________Today’s Date:______________
Occupation:_______________ Date of last MD visit:__________ Who referred you here?_______________
How did this problem start: (circle one):
MVA
Sports Injury Work Injury Chronic Condition Other_________
What part of your body is injured? ______________________________________________________________
Date of Injury:_________ Does this Injury prevent you from working? YES
NO if yes, last date of work________
Current Work Status: __Working without restrictions __ Working with restrictions __ Working different job with
restrictions __ Unable to work __ Unemployed__ Disabled __ Retired__ Normally not working outside the home
What do you see as the major problem /complaint that brings you to therapy?________________________________
What do you hope to achieve in therapy? ______________________________________________________________
Have you had previous physical or occupational therapy? [ ] Yes [ ] No If yes, was your prior therapy
successful? _______________________________________________________________________________________
What did your prior therapy involve? List most helpful versus least helpful. _________________________________
Have you had this problem before: __ yes __ no If this is an acute episode, it started _____days or weeks ago. If
not acute, how long have you had it? _________________
SURGICAL PROCEDURE RELATED TO THIS INJURY? : __________________________________________________
DATE OF SURGICAL PROCEDURE: ___________________________________________________________________
Other surgeries & dates: ____________________________________________________________________________
Are you: RIGHT
OR LEFT
Handed? (Please Circle)
Height: ____________ W eight: ___________
Mark with an “ X “ any symptoms experienced:
[ ] Loss of Feeling
[ ] Weakness
[ ] Paralysis
[ ] Endurance
[ ] Difficulty Walking
[ ] Pain
[ ] Instability
[ ] Pins & Needles
[ ] Bowel control Loss
[ ] Stiffness
[ ] Swelling
[ ] Coordination Loss
[ ] Hypersensitivity
[ ] Other_________
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Mark with an “X” any activities you are having difficulty with:
[ ] Stooping
[ ] Standing
[ ] Handling Objects
[ ] Feeling
[ ] Crouching
[ ] Sitting
[ ] Lifting
[ ] Seeing
[ ] Crawling
[ ] Hearing
[ ] Pushing /Pulling
[ ] Tasting /Smelling
[ ] Reaching
Self-Care Tasks
[ ] Dressing, Bathing etc…
[ ] Kneeling
Home Care
[ ] Tasks
Do you exercise regularly? [ ] Yes [
] No
If so, what do you do? ____________________________
Frequency: ___________ Duration: ____________
What are your hobbies or recreational activities? __________________________________________________
Do you have: [ ] Metal in your body? ___________________________________________________________
Are you allergic to any medications? If yes, list: __________________________________________________
Are you taking any medications? _______________________________________________________________
LIST SPLINTS & BRACES: _____________________________________________________________________
MARK AN “X“ IF YOU HAVE A HISTORY OF ANY OF THE FOLLOWING?
[ ] ARTHRITIS
RHEUMATOID
OSTEO
[ ] CANCER
[ ] LOW BACK PAIN
[ ] TUBERCULOSIS
[ ] DIABETES
[ ] HEART DISEASE
(DO YOU HAVE A PACEMAKER?
[ ] YES [ ] NO
[ ] ASTHMA
[ ] HIGH BLOOD PRESSURE
[ ] KIDNEY PROBLEMS
[ ] SEIZURES
[ ] HEMOPHILIA
[ ] DIZZINESS
[ ] BLURRED VISION ?
[ ] HEPATITIS
[ ] HIV (+) OR AIDS
[ ] OTHER CONDITIONS NOT LISTED?
PRIOR INJURIES?
DO YOU HAVE OTHER WORK RELATED INJURIES? [ ] YES [ ] NO
HOW MANY?
ARE YOU PREGNANT? [ ] YES [ ] NO [ ] N/A
ARE YOU TRYING TO BECOME PREGNANT? [ ] YES [ ] NO
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PLEASE CHECK HERE IF PAIN IS NOT A COMPLAINT
[
]
Please indicate your symptoms on the anatomical diagrams using the symbols in the key.
KEY:
//////// Pain
XXXXX Pain and Needles
OOOOO Numbness
Choose a number on the following scale that best describes the severity of your pain:
PAIN SCALE:
No Pain
0
1
Moderate
2
3
Strong
4
5
Very Strong
6
7
Emergency Room
8
9
10
Average, pain level: __________
At rest, pain level: ____________
With activity, pain level: ___________
Disturbed Sleep: Are you awakened at night by the pain? __Yes __ No
Do you have difficulty getting to sleep? __Yes __ No
Worse (W) or Better (B): In the morning? W or B As the day goes on? W or B In the evening? W or B
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PERFORMANCE AND ATTENDANCE CONTRACT
Welcome to Horizon Therapy Services. We look forward to working with you. Our goal is to
provide quality care in the most efficient and timely manner. Therefore, we tailor a program to
achieve your specific needs and goals. In working with you, we ask the following:
1. The patient /client will report to HORIZON THERAPY SERVICES on time and will remain the entire treatment session. If he /she
is late, the session may be cancelled or rescheduled.
2. The patient /client is expected to meet the prescribed attendance schedule and make up any missed time within the same week.
Absences, late arrivals, and early departures are documented and may be included in the reports sent to the physician, insurance carrier,
rehabilitation counselor /nurse, or attorney. In the event a client cannot keep an appointment, he /she should notify HORIZON
THERAPY SERVICES at least 24 hours in advance. Failure to do so may result in a $25.00 cancellation or no show fee. IF YOU
MISS THREE (3) APPOINTMENTS AND DO NOT CALL OUR OFFICE IN ADVANCE TO CANCEL, YOU WILL BE
DISCHARGED FROM THERAPY.
3. The patient /client should not be under the influence of any intoxicants, un-prescribed drugs, or prescribed medications taken in
sufficient quantity to impair safe function at HORIZON THERAPY SERVICES. Failure to comply may result in discharge from the
program. The patient will inform his /her therapist of any medication currently being taken.
4.
The patient /client will report to HORIZON THERAPY SERVICES in appropriate clothing. Weapons of any nature are not
permitted on the premises.
5. The patient /client will perform in a generally safe manner; will report physical symptoms immediately to the therapist’s instructions
during the evaluation /treatment period.
6. It is the policy of HORIZON THERAPY SERVICES that family members and friends wait in the lobby while you receive treatment
in the therapy areas. Children must remain in the lobby area under the supervision of a responsible adult unless undergoing therapy. If a
minor is the patient/client he /she must be supervised by the parent or legal guarding while in the treatment areas at all times. If your
therapist feels that it is important for a friend or family member to be present, you will be informed of this. Your cooperation is
appreciated.
7. Any information obtained during the interview, evaluation, or treatment process may be documented and included in reports to the
physician, insurance company, rehabilitation counselor /nurse, or attorney.
8. Patient responsibility plays a big role in successful treatment and we have found the following to be critical in that success: attend
scheduled visits, follow and perform Home Programs (if applicable), follow physician and therapist recommendations and directions,
and contact your therapist if a difficulty arises with your treatment.
I have read this Performance Contract, or had it read to me, understand it, and agree to these conditions for evaluation and treatment.
Patient Name: ____________________________________ Date: ________________
Signature: _______________________________________
(Patient /Parent or Legal Guardian)
Witness: ________________________________________
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PATIENT ACKNOWLEDGEMENT
ACKNOWLEDGEMENT RECEIPT OF NOTICE OF PRIVACY PRACTICE
By signing this form, you acknowledge receipt of the Notice of Privacy Practice of Horizon Therapy Services.
Our Notice of Privacy Practice provides information about how we may use and disclose your protected health
information. We encourage you to read it in full. In general it states that:
I understand that Horizon Therapy Services may use or disclose my personal health information for the purposes
of carrying out treatment, obtaining payment. I understand that I have the right to restrict how my personal health
information is used and disclosed for treatment, payment and administrative operations if I notify the practice. I
also understand that Horizon Therapy Services will consider requests for restriction on a case by 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 Horizon
Therapy Services Notice of Information practices. I understand that I retain the right to revoke this consent by
notifying the practice in writing at any time.
Our Notice of Privacy Practice is subject to change. If we change our notice, you may obtain a copy of the revised
notice by contacting the Privacy Officer.
If you have questions about our Notice of Privacy Practice, Please contact the Privacy Officer.
[ ]
I have chosen to waive my right to a copy of this medical practice’s Notice of Privacy Practice.
I understand a copy the current notice will be posted in the Reception area and that I have the
Option to request a copy at a later date if I so choose.
Signature of patient /Parent, Legal Guardian: ____________________________Date: _______________
INABILITY TO OBTAIN PATIENT ACKNOWLEDGMENT
We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practice, but acknowledgment
could not be obtained for the following reason:
[ ]
Individual refused to sign
[ ]
An emergency situation prevented us from obtaining acknowledgment, and an
attempt to obtain acknowledgement will be made at the next available opportunity.
[ ]
Other: (Please Specify) ___________________________________________________
Patient Name: _________________________________________ Date of Birth: ___________________
Staff Signature:________________________________________Date:___________________________
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