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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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: