Patient Data - Premier Physical Therapy and Sports Performance

Name

First Middle Last

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Cell Phone

Home Phone

Email Address

Height

Weight

Sex

Male
Female

Social Security

Emergency Contact Information

Name

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Fill out this section if the primary insured is other than yourself(i.e.spouce/parent)

Name

Primary First Primary Middle Primary Last

Sex

Male
Female

Date of Birth

How did you hear about us?

Guarantor (If other than patient)

Name

First Middle Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Cell Phone

Social Security

Employer

Job Title

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Is this a job related injury?

Yes
No

Is this injury related to an auto accident?

Yes
No

Is this injury related to another accident?

Yes
No

Is a lawyer involved in your case?

Yes
No

When is your next visit to the Doctor?

Please list all persons able to access patient records or updates:

1)

2)

**If you are a returning patient and None of your above information has changed, please sign

Patient Signature

Date

Name

Date

Have you had any of the following in regards to this injury:(Check all that apply)

Cat Scan
MRI
Bone Scan
X-ray
Nerve Conduction Study

If Other Injury

Please list any surgeries you have had including approximate date:

Have you EVER been diagnosed as having any of the following: (Check yes or no)

Cancer Type:

Yes
No

Pacemaker:

Yes
No

Stroke:

Yes
No

Osteoarthritis:

Yes
No

Osteoporosis:

Yes
No

Multiple Scleroasis:

Yes
No

Blood Clots:

Yes
No

Heart Problems:

Yes
No

High Blood Pressure:

Yes
No

Diabetes:

Yes
No

Rheumatoid Arthritis:

Yes
No

Osteopenia:

Yes
No

Depression:

Yes
No

Epilepsy:

Yes
No

Have you experienced any of the following in the last 90 days? If so, please explain:

Constant, severe pain unrelleved by changes in position

Yes
No

Pain that wakes you at night

Yes
No

Pain with coughing, sneezing or straining

Yes
No

Sudden, Unexplanined weight loss or gain or changes in appetite

Yes
No

Recent onset of weakness or difficulty with balance or coordination

Yes
No

Unexplanined changes in bowel or bladder function (frequency, urgency, color, pain)

Yes
No

Pain or difficulty swallowing

Yes
No

Unusual fatigue

Yes
No

Visual Disturbances, Frequent/Severe Headache, Numbness

Yes
No

Fever, Infection or Night Sweats

Yes
No

Patient

Date

Please list any prescription medication that you are currently taking (including pills, injections, over the counter medication herbal supplements, and /or skin patches) **If you are unsure a substance is a medication, please list it for consideration. If you have a list of your medication already prepared please allow us to make a copy for our records and you may leave the medication section blank Thank you.

Medication

Dosage

Frequency

Allergies (of suspected Allergies)

Do you require an EpiPen for your allergies?

Yes
No

Please list any Allergies you have to medication, food, environment or material products.

Injury History Information

Name

Date

Describe your symptoms at present

How did your symptoms begin:

Sudden
Gradual

Other

How long have you experienced these symptoms?

Describe what makes your symptoms worse (positions, movements, activities)

Describe what relieves your symptoms

Presently, are your symptoms:

Improving
Worsening
Staying the same?

When is your pain the worst?

Morning
Mid-day
Night

Have you had anything similar to this is the past?

What treatments have you tried to address your problem?

What are your personal goals for physical therapy?

Have you seen any of the following for this condition? Please check:

Physician
Chiropractor
Message therapist
Personal trainer
Acupuncturist

Name

Date

Height

Weight

Check the number that represents your average pain level over the past week:

Check the number that represents your best pain level over the past week:

Check the number that represents your worst pain level over the past week:

Check the words that describe your symptoms:

Other

CANCELLATION/NO SHOW FEE

Premier Physical Therapy takes great pride in providing all of our patients with exceptional one on care by our Doctors of Physical Therapy. This time is set aside for you and only you. To guarantee or patients the opportunity to be seen in timely manner and to be fair to all patients in scheduling, we require 48 hours working business day notice to cancel a scheduled appointment. If you do not cancel within 48 hours of your schedules appointment time, a $45 cancellation fee will be changed to your account. This cannot be billed to insurance. Please consider that the quality of your care and the amount of improvement you will make depends greatly on your consistency with the appointments you make. (Initial)

By not giving this proper notice, Premier Physical Therapy has my advanced permission to charge my credit card on file any fees associated with missed of cancelled appointment not cancelled within 48 hours notice agreement. If not credit card is on file, I agree to pay this fee at my next scheduled visit or Premier Physical Therapy may bill me any missed visits. I also understand all outstanding missed/no show feed must be paid in-full before any new appointment can be made.

Please Print Name:

Date:

Signature of Insured/Patient:

CONSENT TO TREAT

For and in consideration of the medical treatment, which I many receive while a patient of Premier Physical Therapy & Sports Performance (here after Premier), I either severally or collectively consent to treatment, voluntarily and knowingly, by me if of age and competent of for me, if a minor or incompetent, by my parents, guardian or nearest relative, as the case may be, to the said members of Premier separately or collectively, to carry out, or cause to be carried out such medical treatment, as prescribed or ordered by my physician.

AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF BENEFITS

Ihereby authorize Premier, or any holder of medical information about me to release to the Health Care Funding Administration and its agents (Medicare) or Insurance Companies or Third Parties, any information need to determine these benefits or the benefits payable for related services. I request that authorized Medicare or Insurance payments be made to Premier (to be used only if necessary to file claims.)

AGREEMENT AND RELEASE OF LIABILITY

Ido hereby waive Premier and all employees, and the owner of any responsibility from any injury due to the use of equipment/machinery or any other accident occurring within the facility. I hereby agree to accept responsibility for any and all risks of injury.

PRIVANCY NOTICE

By my signature below, I acknowledge that I have received a copy of the HIPPA Privacy Act “Notice of Information Practices,” and understand my rights as a patient regarding my personal health information.

INSURANCE PROTOCOL

Medicare: Upon receipt of payment and/or denial form Medicare, your secondary insurance will be billed as a courtesy, one time only per date of treatment. If there is a remaining balance after all insurance companies have been billed you will be responsible for this balance which will be provided for you in the form of a statement. Commercial/Group: Before your initial evaluation our office will verify your benefits. You will be expected to pay your co-pay or coinsurance at the beginning of each vis

GUARANTOR RESPONSIBILITY

I understand that I am ultimately responsible for payment of any and all charges for medical services rendered by Premier and if this assignment is rejected, modified or not paid within a reasonable time after it has been filed, it will be my responsibility to pay any unpaid charges in full. If it is necessary to collect unpaid fees for services rendered, I agree to pay the charge assessed by the collection service, legal counselor court. I may revoke this authorization and assignment at any time by written notice. I agree that a copy of this form may be used in lieu of the original.

Please Print Name

Date

Signature of Insured/Patient

Emergency Contact Information

Fill out this section if the primary insured is other than yourself(i.e.spouce/parent)

Guarantor (If other than patient)

Please list all persons able to access patient records or updates:

**If you are a returning patient and None of your above information has changed, please sign

Have you EVER been diagnosed as having any of the following: (Check yes or no)

Have you experienced any of the following in the last 90 days? If so, please explain:

Allergies (of suspected Allergies)

Injury History Information

CANCELLATION/NO SHOW FEE

CONSENT TO TREAT

AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF BENEFITS

AGREEMENT AND RELEASE OF LIABILITY

PRIVANCY NOTICE

INSURANCE PROTOCOL

GUARANTOR RESPONSIBILITY

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