Download I verify that the above information is accurate (Signature)

PATIENT REGISTRATION
Name
Date
Last
First
Mailing Address
_
Street
MI
_
_
Physical Address_
Work
Social Security Number _
Single
_
State
Work Phone
Home
E-mail Address
_
Birth date
Married
_
Sex:
Domestic Partner; Registered in:
Employer
Zip Code
Cell Phone
Cell
_
Zip Code
_
City
Home Phone w/area code
Marital Status:
State
_
Street
Contact Preference:
_
City
_ Spouse/Partner’s Name_
Female
Male
Divorced
Employer’s Address
Widowed
_
Prescribing Physician (If different)
Primary Care Physician
Emergency Contact
_
Home Phone w/area code
Relationship_
_
Work Phone
Cell Phone _
INSURANCE INFORMATION – PLEASE GIVE YOUR CARDS TO THE FRONT DESK FOR SCANNING
Primary Insurance
Subscriber’s Name
Birth date
ID Number
Group Number
Secondary Insurance
Subscriber’s Name
Birth date
ID Number
Group Number
IF YOU HAD AN ACCIDENT PLEASE COMPLETE THIS SECTION
Date of accident
_
Claim Number
_
How did it happen?
Auto
Work
Other
State in which injury occurred_
Insurance Company (worker’s comp or your auto PIP)
Address
_
_
Claims Adjuster_
Phone number
I verify that the above information is accurate (Signature)
_
_
_
Please tell us how you learned of our service or whom we can thank
Former patient name:
I was a Former Patient
Former Patient recommendation
Family/Friend/Co-Worker recommendation
Doctor recommendation
Yellow Page advertisement
Found you on the Internet
Website:
_
TV/Billboard advertisement
Publication/Newspaper advertisement
Publication : _
_
Clinic Sign
I saw you at an Event
Friend/ Family:
Event:
PATIENT INQUIRY/ HEALTH HISTORY
NAME:
DATE:
To insure you receive a complete and thorough evaluation. please provide
us with important background information on the following form. If you do
not understand the question, your therapist will assist you. Thank you.
HISTO RY OF PRESENT CONDITION
7. Nature of pain/symptoms (check all that apply)
(1) sharp
(2) dull
(3) throbbing
1. What are your symptoms?
(4) aching
(5) periodic
(6) occasional
(7) constant
(8) other
8. As the day progresses, do your symptoms: (Check one)
Localize areas of pain or abnormal sensation on the
body chart below (Shade in where appropriate)
(1) increase
(2) decrease
(3) stay the same
9. Does the pain wake you at night?
(1) No
if “yes”, is it present
(1) while lying still
(2) Yes
(2) only when changing positions
(3) both
10. Do you have pain/stiffness upon getting out of bed in the
morning?
(1) Yes
(2) No
11. In what position do you sleep? (Check all that apply)
(1) right side
(2) left side
(3) stomach
(4) back
(5) chair/recliner
(6) back, sides, stomach
(7) other
12. Since the onset of your current symptoms have you had:
(1) any difficulty with control of bowel or bladder function
(2) fever/Chills
(3) any numbness in the genital or anal area
(4) numbness
(5) any dizziness or fainting attacks
(6) weakness
(7) unexplained weight change
(8) night pain/sweats
(9) malaise (vague feeling of bodily discomfort)
(10) problems with vision/hearing
(11) none of the above
2. When did your symptoms begin?
(Please indicate a specific date if possible)
13. What aggravates your symptoms? (Check all that apply)
3. Was the onset of this episode gradual or sudden?(Check one)
(1) gradual
(2) sudden
4. Which of the following best describes how your injury
occurred? (if your condition is post-surgical please indicate as
per original injury)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
lifting
a MVA (car accident
a fall
overuse (cumulative trauma)
trauma
degenerative process
during recreation/sports
running
(9) a blow to the face
(10) being hit by a ball
(11) a dental appointment
(12) throwing
(13) an incident at work
(14) unknown
(15) other
(2) worse
(9) repetitive activities
including
(10) household activities
including
(11) standing
(12) squatting
(13) sleeping
(14) coughing/sneezing
(15) taking a deep breath
(16) looking up overhead
(17) swallowing
(18) stress
(19) sustained bending
(20) other
14. What relieves your symptoms? (Check all that apply)
5. Since onset, are your symptoms getting: (Check one)
(1) better
(1) sitting
(2) going to/rising from sitting
(3) lying down
(4) walking
(5) up/down stairs
(6) reaching overhead
(6) reaching in front of body
(6) reaching behind back
(6) reaching across body
(7) talking, chewing, yawning,
all (circle one)
(8) recreation/sports including
(3) not changing
6. Have you had similar symptoms in the past? (1)
More than one episode? (1) Yes (2)
No
Yes (2)
No
(1) sitting
(2) heat
(3) cold
(4) stretching
(5) wearing a
splint/orthosis
(6) rest
(7) standing
(8) walking
(9) exercise
(10) lying down
(11) massage
(12) medication
(13) nothing
(14) other
15. Have you had any previous treatment for this condition?
(Check all that apply)
(1) none
(2) medication (oral)
(3) joint manipulation
(4) exercise
(5) massage therapy
(6) traction
(7) bracing/taping
(8) injection into the spine
(9) injection into the skin/muscles
(10) physical therapy
(11) hypnosis
(12) biofeedback
(13) TENS unit
(14) acupuncture
(15) bed rest
(16) overnight
hospitalization
(17) casting
(18) other
LIVING SITUATION
live alone
(6) assisted living
live with family members/others
complex
live with caregiver
(7) other
home/apartment
retirement complex (SNF/ICF)
Setting
(1) stairs (railing)
(2) stairs
(no railing)
(3) no stairs
(4) ramp
(5) elevator
(6) uneven ground
(7) other
GENERAL H EALTH
How would you rate your general health?
16. Have you had any of the following tests?
(1) none
(2) x-rays
(3) CT Scan
(4) MRI
(5) Arthrogram
(6) Stress X-ray Test (Telos)
Test Results:
(1)
(2)
(3)
(4)
(5)
Excellent
Good
(7) Bone Scan
(8) NCS
(9) Fluoroscope
(10) Vestibular
(11) other
Average
Fair
Poor
Do you exercise outside of normal daily activities?
5+ days/wk
1-2 days/wk
3-4 days/wk
occasionally
Exercise, Sports/Recreation consisting of
zero
,
MEDICATION
If you have a current exercise routine is it:
Please list any prescription medications you are currently taking
(pain pills, injections and/or skin patches, etc.):
Lite
Moderate
Do you smoke?
No
Are you currently taking any of the following over the counter
medications?
(1)
(2)
(3)
(4)
(5)
aspirin
Tylenol
corticosteroids
antihistamines
vitamins/mineral supplements
PREVIOUS
(6) Advil/Motrin/
Ibuprofen
(7) other
FUNCTIONAL
LEVEL
Independent in all self-care activities (bathing, toileting, dressing,
etc.)
Difficulty performing self-care activities
Need assistance with self-care activities
Difficulty performing household chores
Social
Need assistance with activities in community outside of home
Hobbies:
WORK HISTO RY
(1)
(2)
(3)
(4)
employed full time
employed part time
self employed
homemaker
(5) student
(6) retired
(7) unemployed
(8) other
Physical activities at work (check all that apply)
(1)
(2)
(3)
(4)
(5)
sitting
standing
phone use
repetitive lifting
heavy lifting
(6) computer use
(7) heavy equipment
operation
(8) driving
(9) other
Are you currently receiving or seeking disability for this
condition?
(1) Yes
(2) No
If not performing your normal activities at work do you plan to
RETURN to your previous activity level?
(1) Yes
(2) No
Packs of cigarettes per day
What is your stress level?
Low
Medium
High
Are you seeing any health care providers other than RXU physical
therapist for this current condition? (Please list)
Independent in all activities (work, community, home,
recreation)
Self-care
Occupation
Yes
Intense
PAST MEDICAL HISTORY
Have you ever had/been diagnosed with any of the following
conditions? (Check all that apply)
Cancer (type)
Depression
Stroke
Kidney problems
Thyroid problems
Diabetes
Multiple sclerosis
Arthritis
injury
Stomach problems
Parkinson’s disease
Infectious diseases
(i.e. hepatitis, tuberculosis, etc.)
Heart problems
High blood pressure
Lung problems
Blood disorders
Epilepsy/seizures
Allergies
Rheumatoid arthritis
Osteoporosis Head
Broken bone
Circulation/vascular
problems
Other
Please list any recent/relevant past surgeries related to your
current problem:
SURGERY
DATE
FAMILY HISTORY
Has anyone in your immediate family (parents, brothers, sisters)
ever been treated of any of the following?
Diabetes
Heart disease
High blood pressure
Stroke
Other
Cancer
Arthritis
Osteoporosis
Psychological condition
Please circle preferred contact
Home Phone:
leave a detailed message: □ Yes □ No
Cell Phone:
Work Phone:
leave a detailed message: □ Yes □ No
Email Address:
leave a detailed message: □ Yes □ No
leave detailed message: □ Yes □ No
Quality Physical Therapy can share my health info with (limits below):
Name:_
Name:
Relation:_
Relation:
Time Limits share records from:
For How Long
□ Anytime (past/now/future)
□ Indefinite
□ Only from
□This date/event:
to
Name:
Relation:_
Topic Limits share records:
□ Alcohol/Drug abuse treatment
□ General records & include
□ Mental Health
□ Communicable diseases including HIV/AIDs
Name:
Relation:
Cancelling
I can cancel this permission, in writing,
at any time. But I can’t retroactively
cancel permission, or cancel for my
insurance if it part of my coverage agreement.
 After sharing Quality Physical Therapy Inc.,P.S. can control the privacy of the patient but is unable to control how the
designees share it.
No shows & Cancellations : Cancellations or changes should be made twenty-four hours prior to your scheduled time. Failure to notify the
office can result in an imposed personal fee. If a client has an excessive number of cancellations, future appointments the patient will be
subject to calling for same day availability.
Late arrival: We understand unforeseen circumstances can keep you from your appointments at their scheduled time. In such a situation we allow
you a grace period of up to 15 minutes. Your treatment time will end at its scheduled time so other patients will not have to wait. If you are not able
to make it in the time frame allotted we can reschedule a better time.
Financial Policies: We recommend that you confirm what your insurance plan covers with our company prior to making an appointment given
the diversity of each plan. As a courtesy we will verify your insurance benefits and will assist you with any questions.
We do offer a discount for uninsured cash paying clients.
The only form of secondary insurance we bill is Medicare recipients. We will help you with any information needed to bill your secondary.
You will be responsible for any money owing on your account, this includes any denials, adjustments, co-payments, co-insurance, and/or deductible.
Payments are to be made at the time of service or after receipt of your finalized bill. Our office personnel can make payment arrangements with
you if your financial situation will not allow you to pay your bill in full. If you do not contact us and your account is seriously overdue, it may end
up being sent to collections.

Please advise us as soon as possible of any changes that may affect your billing, Ex.: new address, employment, injury,
or insurance change. Privacy statement
Quality Physical Therapy Inc. P.S. will use and disclose your personal health information for your treatment, billing, and other healthcare operations.
We have a detailed NOTICE OF PRIVACY PRACTICES which details policies in regards to your personal health information. You have the right to
review the notice of privacy practices before agreeing to consent. The terms in the notice may change at any time, updated a copy will be
distributed upon request. By signing you are acknowledging receipt of this information.

I understand that I am financially responsible for all charges and services rendered regardless of litigation, insurance reimbursement, or
pending claims. I
understand that the parent/ guardian of a minor will be
responsible for payment.

I am authorizing Quality Physical Therapy to release any necessary information requested by my insurance carrier and authorize
payment directly to Q.P.T. for any benefits available under my insurance plan.

I understand that QPT is not responsible for any personal belongings I bring to the clinic.

I hereby consent to treatment and acknowledge that I have read and understand the cancellation, no-show, and financial policies as stated
above.
Patient Signature:
Date: