Corona-Temecula Orthopaedic Associates P H Y S I C A L T H E R A P Y A N D W E L L N E S S C E N T E R
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- Catherine Blair
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1 PATIENT QUESTIONNAIRE Please fill out this form COMPLETELY using your LEGAL name. Do not leave any blanks. FAMILY PHYSICIAN (First Name, Last Name) PATIENT INFORMATION DATE TO SEE DOCTOR (Name) / / PATIENT S LEGAL NAME: (Mr./Miss/Mrs./Ms. First, Middle, Last) PATIENT S ADDRESS CITY STATE ZIP DATE OF BIRTH AGE SEX MARITAL STATUS SOCIAL SECURITY NUMBER / / ( ) M ( ) F ( ) M ( ) S ( ) D ( ) W X X X X X RESPONSIBLE PARTY / SUBSCRIBER INFORMATION (If different than above) NAME (Last, First, Middle Initial) SSN# X X X X X PRIMARY ADDRESS PRIMARY CARE PHYSICIAN PHONE PRIMARY INSURANCE NAME OF INSURANCE COMPANY TO NAME OF PRIMARY MEMBER INSURED SECOND CONTACT BILLING ADDRESS (If Applicable) RELATIONSHIP TO PATIENT POLICY # GROUP # ADDRESS OF INSURANCE COMPANY CO-PAY AMT DEDUCTIBLE SECONDARY INSURANCE (If Applicable) NAME OF INSURANCE COMPANY NAME OF PRIMARY MEMBER INSURED EFFECTIVE DATE POLICY # GROUP # EXPIRATION DATE ADDRESS OF INSURANCE COMPANY CO-PAY AMT DEDUCTIBLE EFFECTIVE DATE EXPIRATION DATE REFERRAL SOURCE (How did you hear about our Medical Group) ( ) INTERNET / WEBSITE ( ) FAMILY MEMBER ( ) HOSPITAL ( ) OTHER AUTHORIZATION OF TREATMENT, ASSIGNMENT OF BENEFITS AND RELEASE OF INFORMATION I authorize payment of benefits directly to CORONA-TEMECULA ORTHOPAEDIC ASSOCIATES of the surgical and/or medical benefits if any, otherwise payable to me for their services. I understand that I am financially responsible for any charges not covered by insurance benefits and I am also responsible for any collection or local costs incurred should such costs be necessary for the processing of insurance benefits or medical and/or services rendered. I hereby authorize treatment by CORONA-TEMECULA ORTHOPAEDIC ASSOCIATES. SIGNATURE OF PATIENT/GUARDIAN DATE SIGNATURE OF INSURED DATE Assistant
2 GENERAL INFORMATION Medical History and Current Symptoms Name Date Name of Referring Physician Age: Date/Time of Next Doctors Appt: Date of Birth Hand Dominance: Right / Left Foot Dominance: Right / Left Gender Male / Female Occupation Are you Currently Working Yes / No Working Status (circle one) Full Duty / Modified Duty / Not Applicable How did you hear about us? ONSET AND CURRENT CONDITION 1. Describe the pain or problem(s) in which you are seeking physical therapy. 2. Circle all that describe the pain or problem(s). Sharp Aching Clicking Pulsating Tightness Numbness Burning Stabbing Dull Popping Throbbing Pulling Shooting Tingling Soreness Heavy Weakness Deep 3. What was the cause of this problem (how did the injury occur)? 4. Was the cause of the problem(s) sudden or gradual? 5. What was the date of injury/onset of your problem(s) (be as specific as possible)? / / 6. Date of surgery (if applicable): / / 7. Have you had this problem before? Yes / No If yes, 1. What treatment was provided? 2. How long did your symptoms last? 3. Did the problem get better, worse or stay the same? 4. Does this problem feel similar to the previous problem? 8. What activities, positions, or actions increase your symptoms? 9. What activities, positions or actions decrease your symptoms? Assistant
3 10. Place a line between 0 and 10, 10 being the worst imaginable pain, which best describes your pain level. Currently: none mild uncomfortable moderate distressing horrible excruciating At its Best: none mild uncomfortable moderate distressing horrible excruciating At its Worst: none mild uncomfortable moderate distressing horrible excruciating 11. Consistency of your pain or problem (circle one): Constant / Sporadic / Varying 12. Since onset, are your symptoms (circle one): Improving / Stable / Getting worse 13. What are your goals from Physical Therapy? 14. What clinical tests have you had within the last year? Reason Date o X-rays o MRI o CT Scan o Nerve ConductionStudy o EKG o Angiogram o Stress Test (Treadmill, Bike, Etc.) o Biopsy o Other 15. Please list ALL medications you are currently taking. Medicaiton Dose Frequency 16. Please list ANY allergies. 17. Have you had Physical Therapy in the Past? o Yes o No Date: Injury: Clinic: Assistant
4 SOCIAL HISTORY 1. Do you smoke or use any form of tobacco? o Yes o No If Yes, How many a Day? For how long? 2. Do you consume alcohol? o Never o Daily o Once a Week o Once a Month o Once a Year 3. Describe your exercise history over the last year. Example: Biking, 30 minutes per day, 4 days per week Activity Type Minutes/Day Days/Week 4. Highest level of education completed? CURRENT SYMPTOMS & LOCATIONS Please draw your current symptoms and the location on the body chart utilizing the symbols in the parenthesis. You may use as many of the following descriptions as indicated. Aching (//////) Burning (bbbb) Numbness (xxxx) Pulling (pppp) Pins & Needles (= = =) Stabbing (+++) Tightness (zzzz) other (oooo) Assistant
5 MEDICAL HISTORY Patient Yes / No Family Member Yes / No 1. High blood pressure?... o o o o 2. Heart or cardiac problems?... o o o o 3. Angina/Chest pain?... o o o o (If you answer no to this question, proceed to number 4) Does your chest pain occur with coughing or breathing?... o o N/A Is your chest pain relieved after eating?... o o N/A Does you chest pain occur hours after a heavy meal or alcohol consumption?... o o N/A Does your current chest pain improve in an upright or comfortable position?... o o N/A 4. Currently pregnant?... o o N/A 5. Do you wear a pacemaker?... o o N/A 6. Unexplained weight loss/weight gain?... o o N/A 7. Night Pain?... o o N/A 8. Diabetes?... o o o o 9. History of seizures?... o o o o 10. Circulatory Problems?... o o o o 11. History of strokes?... o o o o 12. Osteoporosis?... o o o o 13. Osteoarthritis?... o o o o 14. Rheumatoid Arthritis?... o o o o 15. History of cancer?... o o o o 16. Asthma?... o o o o 17. Kidney Disease?... o o o o 18. Depression?... o o o o 19. Panic or anxiety disorder?... o o o o Patient Have you had any of the following in the past year? Yes / No 1. Recent episode of fever, chills, or sweats?... o o 2. Chronic Fatigue?... o o 3. Change in Appetite?... o o 4. Recent onset of difficulty retaining your urine or bowel?... o o 5. Weakness, tingling, numbness, or shooting pain in your lower extremities?... o o 6. Numbness in the area of your bottom where you would sit on a bicycle seat?... o o 7. Difficulty with hearing, seeing, speaking or swallowing?... o o 8. Headaches or migraines?... o o 9. Loss of consciousness or a history of a head injury?... o o 10. Diagnosed with an immunosuppressive disorder?... o o 11. Sexually transmitted disease?... o o 12. Currently present with an open wound or redness around the wound?... o o 13. Weakness, numbness, tingling, or shooting pain in your upper extremities?... o o 14. Recently had a trauma, such as a fall or a motor vehicle accident?... o o 15. Weakness in your hands or an increased frequency of dropping objects?... o o 16. Increase of pain with weight bearing?... o o 17. Currently taking steroids or have had prolonged steroid therapy?... o o 18. Cortisone injection into one or more joints?... o o If yes, what joint(s)? How many shot(s)? Last injection (date)? 19. Please list any other relevant medical conditions. 20. Please list all surgeries you have had and the date. Assistant
6 Physical Therapy Policies In order to ensure a safe and positive experience while in physical training, we ask that you please abide by a few guidelines. Co-payments are due at the time of service. Co-insurance or share of cost will be billed to the insurance first then you will receive a bill for your portion. Please be aware that you are responsible for any charges not covered by your insurance company. As a safety precaution, children or guests are not allowed in the gym during your visit. They will be asked to wait in the waiting room. Shoes must be worn at all times. No sandals or open toe style shoes. No food or beverages allowed in the gym area. We do not allow cell phone use in the gym during therapy. Please call in advance if you are unable to attend your scheduled appointment or if you are going to be late, so we can adjust our schedule accordingly. Please be prepared to expose the body part being treated. Gowns will be provided for your neck or back. We the staff of Corona-Temecula Orthopaedic Physical Therapy are dedicated to providing you with the best quality care. To achieve this we ask for your assistance. As the patient it is your responsibility to follow the recommendations of your and Physician. It is necessary that you attend all of your appointments, and be consistent with your home exercise program in order to achieve your goals. Signature: Date: By signing, I declare that I have read and understand the above outlined policy. Assistant
Personal Insurance Intake Form
Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: - - Address: Street City State Zip Email Address: Home Phone: Cell Phone: Gender: Height: Weight: lbs Marital Status:
Worker s Compensation Intake Form
Worker s Compensation Intake Form Patient Information Date of Birth: / / Social Security: - - Address: Street City State Zip Email Address: Home Phone: Cell Phone: Gender: Height: Weight: lbs Marital Status:
Patient Registration. D. INSURANCE (if applicable)
Patient Registration A. PATIENT Account #: Address: City: State Zip: Preferred Contact Method: Home Phone Work Phone Cell Phone DOB: SSN #: Gender: Male Female E-MAIL: Check here to receive Electronic
PATIENT INFORMATION : Please present insurance cards to receptionist. INSURANCE: Please fill out only if you re NOT the subscriber
PATIENT INFORMATION : Please present insurance cards to receptionist First Name: Last Name: Date of Birth: - - Sex: Male Female Address: City: Cell Phone #: ( ) - M.I.: APT: State: Zip Code: Home #: (
PHYSICAL THERAPY CENTRAL
PHYSICAL THERAPY CENTRAL PATIENT INFORMATION Patient Name: Address: City: State: Zip: Employer: Birthdate: Age: Home Phone: Cell Phone: Work Phone: Preferred Contact Method for Appointment Reminders: Home
Marital Status Patient s Last Name First Initial Date of Birth S M D W. Home Phone Work Phone Mobile Phone . Address City State Zip
PATIENT INFORMATION Marital Status Patient s Last Name First Initial Date of Birth S M D W Home Phone Work Phone Mobile Phone E-Mail Address City State Zip Occupation Employer Employer Phone Employer Address
(Formerly AFCN Physical Medicine) A member of the Arkansas Family Care Network, P.A.
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Registration Form. Gender: Male Last Name First Name Middle Initial Female. - - / / Social Security Number Date of Birth Age Occupation / Employer
Registration Form General Information Have you been treated by us before? Yes No Gender: Male Last Name First Name Middle Initial Female Social Security Number of Birth Age Occupation / Employer Street
3 Emergency Contact. Eaton Chiropractic & Rehab Center. 1 Patient Information. 2 Insurance / Guarantor. 4 Accident Information. Emergency Contact:
Eaton Chiropractic & Rehab Center 1 Patient Information Name: First Initial Last Address: Home: Work: Cell: DOB: Male Sex: Female SSN: Email: Single Divorced Marital Status: Married Separated Widowed Full
Patient Registration. D. INSURANCE (if applicable)
A. PATIENT Please Print Legibly Account #: Address: City: State: Zip: Preferred Contact Method: Home Phone Work Phone Cell Phone Patient Registration DOB: SSN #: Gender: Male Female E-MAIL: Check here
Chiropractic Case History / Patient Information
Chiropractic Case History / Patient Information Date: Name: Social Security #: Home Phone:( ) Address: City: State: Zip: E mail address: Cell Phone:( ) Age: Birth Date: / / Marital Status: M S W D Occupation:
BenchMark Rehab Partners Welcome to
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Patient Information Date: Name: Birth Date: Age: Marital: M S W D Address: City: State: Zip: E-mail address: Phone: Occupation: Employer: Spouse: Occupation: Employer: How many children? Names and ages
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AMR PAIN AND SPINE CLINIC, LLC NABIL AHMAD, MD Today's : Email: Patient Last Name: First: Middle: of Birth: / / Sex: (circle) Male Female Marital Status: (circle) M S D W Street Address: Social Security
PATIENT INFORMATION Patient Demographics and Insurance
PATIENT INFORMATION Patient Demographics and Insurance PERSONAL INFORMATION Last First MI Suffix Social Security # Date of Birth Sex Marital Status Primary Phone Alternate Phone Email Address Address City
PRINT CLEARLY. Name: (first) (last) (m.i) Address: City: State: Zip:
PRINT CLEARLY NEW PATIENT FORM Name: (first) (last) (m.i) Address: City: State: Zip: Email: Sex: Male Female Student Yes No Home Ph: Cell Ph: Work Ph: Fax: Age: Of Birth: Statement Preference: E-mail Fax
KORT New Patient Information
managed by: KORT New Patient Information Patient Address: City/State/Zip: E-Mail Address: Date of Birth: / / Age: Sex: Social Security Number: - - Marital Status: Home Phone: Cell phone: Employer/School:
Tracy Blum Physical Therapy, Inc NEW PATIENT REGISTRATION FORM PATIENT INFORMATION. Last Name: First Name: Middle Initial: Social Security no.
Tracy Blum Physical Therapy, Inc NEW PATIENT REGISTRATION FORM PATIENT INFORMATION Last Name: First Name: Middle Initial: Date of Birth: / / Age: Sex: M F Social Security #: / / Marital Status (circle
Please feel free to ask questions about this document. I have read the above guidelines and agree to the terms set forth by A Joint Effort PT.
Please arrive to your initial appointment at least 15 minutes early. For all following appointments, please arrive 5 minutes prior to you scheduled appointment time. To avoid waiting unnecessarily remember
Patient Registration & Health History
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2345 Court Drive Gastonia, NC Phone: Fax:
Patient Name: Address: Street City State Zip SSN: Home #: Birth Age: Sex: Male Female Email Address: Marital Status: Single Married Divorced For X-ray purposes, are you pregnant? Yes No Patient s Employer:
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Acknowledgment of Receipt of Notice
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OSI PHYSICAL THERAPY AUTHORIZATION TO TREAT: I voluntarily consent to therapy care encompassing evaluation and treatment procedures. I acknowledge that no guarantees have been made to me about the results
4) Address: City, State, Zip Code 5) Gender: Male Female 6) Date of Birth (DOB): / /
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Patient Demographic Information Patient s Name: Date: SS#: DOB: Age: Sex: F M Home Address: Marital Status: Single Married Widow Divorced Separated City: State: Zip: Home Phone: Cell Phone: Work Phone:
Demographic Information
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Patient Information Page 1 of 2 *We cannot process your insurance claims without the required fields filled out.
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Body Basics Physical Therapy Medical History
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First Name MI Last Name. Address. City State ZIP. Phone (H) (W) (Cell) (Please circle the preferred contact number) Address
Date of Birth Social Security Number - - First Name MI Last Name Address City State ZIP Phone (H) (W) (Cell) (Please circle the preferred contact number) Email Address Occupation Full Time/Part Time Employer
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Informed Consent for Physical Therapy Services
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Myofascial Treatment Center of Modesto Patient Information Sheet
Myofascial Treatment Center of Modesto Patient Information Sheet Last Name First Name Middle Initial Mailing Address City State Zip Code / / Home Phone Number Date of Birth Age Female Male Email address
CHIROPRACTIC REGISTRATION AND HEALTH HISTORY FORM
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New Patient Mobility Intake Form NAME: DATE OF BIRTH: Address City State Zip Code Phone Gender Male Female Height Weight Social Security Number Email address Primary Insurance Group # -- Secondary Insurance
FREDERICKSBURG ORTHOPAEDIC ASSOCIATES, P.C. PHYSICAL THERAPY INSTITUTE PATIENT INFORMATION SHEET
PATIENT INFORMATION SHEET Chart #: Today s : FOA Initials: PATIENT INFORMATION Last Name, First Name, MI: Home Phone: Cell Phone: SSN: Birth (MM/DD/YYYY): Age: Sex: Marital Status: Single Separated Male
NEW PATIENT CHECKLIST
80 Park Street, Attleboro, Ma 02703 508-223-2300 NEW PATIENT CHECKLIST If you need to see a physical therapist, you want to get the most out of each and every visit. Before you can show up for a visit,
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GIVE US STRENGTH PHYSICAL THERAPY
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MICHAEL K. BLOCK, DPM, LLC PATIENT FINANCIAL POLICY
MICHAEL K. BLOCK, DPM, LLC PATIENT FINANCIAL POLICY Dear Patient, Thank you for choosing Michael K. Block, DPM, LLC for your podiatric needs. We value our relationship with you and would like to tell you
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REFERRED BY FAMILY DOCTOR DARRELL C. BRETT, M.D., P.C. BRET GENE BALL, LLC 10,000 SE MAIN, SUITE 360 PORTLAND, OREGON 97216 NEUROLOGICAL SURGERY PATIENT INFORMATION (PLEASE PRINT) DATE PATIENT S LAST NAME
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Emil W. Tetzner, D.M.D., M.S. Practice Limited to Periodontics *Please complete both sides AND MAIL BACK TO OUR OFFICE* Name Street City & State Zip Code Home Phone Business Phone Cell E-Mail Birth Date
Patient Information. Referred by: Primary Care Physician: Last Name: First Name: Mr. Mrs. Miss Other Middle Name: Preferred Name:
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PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING (INCLUDE PRESCRIPTIONS, OVER-THE-COUNTER MEDS AND HERBAL SUPPLEMENTS): NAME DOSE HOW OFTEN DO YOU
ADVANCED FOOT CARE SPECIALISTS, P.C. 240 W. PASSAIC STREET, SUITE 4 * MAYWOOD, NEW JERSEY 07607 * TEL: 201-880-6000 FAX # 201-880-5999 PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / / PATIENT NAME: DATE
MassageWorks Patient Information
MassageWorks Patient Information Personal Information Name of Birth Age Sex Male Female Address City State Zip Home Phone Cell Phone Email Marital Status Single Married Divorced Widowed Other Emergency