PATIENT INTAKE. Date of Birth. Occupation Relationship to Patient(circle) Self Spouse Parent Other
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1 Appointment Date: Therapist: Personal Information Patient Name Nickname(s) or Preferred Name Home Address City, State, Zip Code Home Phone # Work Phone # Cellular Phone # Date of Birth Social Security Number (SSN) Sex: M or F Employer Employer Address City, State, Zip Code Occupation Marital Status M S D W Emergency Contact: Name and Phone # Address: PATIENT INTAKE Age POLICY HOLDER/RESPONSIBLE PARTY INFORMATION Name (last/first/m) Address City, State & Zip Code Phone # Work # Cell # Gender Male Female Social Security # (SSN) Employer Date of Birth Occupation Relationship to Patient(circle) Self Spouse Parent Other Boise: 1673 W. Shoreline Drive, Suite 230, 83702
2 Boise: 1673 W. Shoreline Drive, Suite 230, PATIENT HISTORY FORM Patient Name: Date of Birth: Current Conditions/Chief Complaint: Describe the problem for which you seek physical therapy: When did the problem begin? What happened? Have you ever had this problem before? If yes, explain. What aggravates or makes your problem worse? What eases or makes your problem better? What are you currently doing to make your problem better? What are your goals for physical therapy? Functionally, what are you having difficulty with? (For example: driving, walking, prolonged sitting, lifting, working.) Current Medication (please list all): Are you allergic to any medications? (please list all): *Please Complete Next Page*
3 Functional / Social Questions: Medical History: Surgical History: Are you currently working? Y N Full duty, no limitations? Y N If not working, how long have you been out of work? -Difficulty with self-care? Y N -Difficulty with home management (as shopping, care of dependents, chores)? Y N -Difficulty with work activities? Y N With whom do you live? (circle) Are you experiencing any of the following? Alone, Spouse, Group setting, Caregiver, 1. Fever/chills/sweats Child(ren), Other 2. Nausea/vomiting Do you feel you need social services/counseling for any of 3. Dyspnea (difficulty breathing) these concerns? Y N 4. Recent onset of weakness 5. Syncope/dizziness 6. recent change in bowel or bladder control Have you undergone any diagnostic testing for this problem (x-rays, MRI, CT Scan, EMG, ect.)? please refer to the Pain Intensity Scale to answer the following questions. At Best At Worst Average At This Moment Pain Intensity Scale 0 No Pain 1 Low: No pain medications. Normal levels of activity, 2 except for heavy types. 3 4 Moderate: Regular use of pain medications and possibly muscle 5 6 relaxants. Activity is very limited, but functional for family & social roles. 7 High: Regular use of pain, anti-inflammatory & muscle relaxant 8 medication. Activity limited to necessary self-care Emergency Situation Please mark on the body chart the site(s) of pain for which you are seeking physical therapy.
4 Boise: 1673 W. Shoreline Drive, Suite 230, OUTPATIENT SERVICES CONSENT FOR TREATMENT Please read carefully Consent for Treatment: I authorize the staff at Foothills Physical Therapy to undertake such treatment and procedures as deemed appropriate to improve my condition. It is recognized that the practice of medicine is not an exact science and, as such, no guarantees are made by the staff of Foothills Physical Therapy as to the results of treatment or interventions performed. I am advised that I have the full right to a full explanation of any treatment or procedure utilized. I understand that I have the right to refuse treatment; but, in doing so, I also understand that the desired outcome of my treatment program may by affected. Persistent refusal to participate or cooperate in the recommended treatment program may result in my discharge from the program. Personal Property: It is understood that Foothills Physical Therapy shall not be liable for loss or damage to any personal items brought to Foothills Physical Therapy during your course of treatment. Release of Information: Foothills Physical Therapy may disclose all or any part of my records to any party or organization responsible for all or part of my therapy charges. Foothills Physical Therapy may disclose all or part of my record to other health care providers including but not limited to, hospitals and physicians. I further agree that Foothills Physical Therapy may release all or any part of my record to any federal, state, or local government body when, in the opinion of Foothills Physical Therapy such bodies may be liable for all or part of my charges in relation to my care and treatment pursuant to statute or rule. Financial Consent: I agree to be responsible for payment of all outpatient physical therapy charges which are not covered by insurance, and when appropriate, to submit applications to federal, state, and county programs. I understand Foothills Physical Therapy will bill me, my family, and/or other responsible parties for services provided. Assignment of Insurance Billing: I and/or the responsible party voluntarily assign Foothills Physical Therapy and its independent contracting providers the right to pursue their respective claims for reimbursement from any insurance policy or policies providing coverage for services provided. Notice of Privacy Practices: I hereby acknowledge that I have received a copy of Foothills Physical Therapy s Notice of Privacy Practices on this day. (Please complete back side)
5 CANCELLATION & NO SHOW POLICY: Foothills Physical Therapy is founded upon, one-on-one, quality care. We are dedicated to providing an empowering environment with individualized care to achieve optimal healing and functional recovery for our patients. In keeping with our mission we ask that our patient be adherent to their scheduled physical therapy appointments. If you should have to cancel an appointment, we kindly request at least 24 business hours notice. For patients who do not provide at least 24 business hours advance notice, if we feel it is necessary we will charge you a $35 fee. Repeated cancellations and/or not showing up to appointments do not align with the Foothills Physical Therapy mission. Please be advised if you cancel and/or no show for 3 physical therapy appointments your therapist may discharge you from care and send your referring provider a note regarding your non-adherence to your therapy plan of care. Signed (patient/representative) Date Witness If you have any questions please ask the front desk. Thank you, Foothills Physical Therapy.
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