PRIME CARE PHYSICAL THERAPY, P.C. NEW PATIENT INFORMATION
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1 PRIME CARE PHYSICAL THERAPY, P.C. NEW PATIENT INFORMATION Patient Name: Last First MI ( ) Male ( ) Female Address: Street City State Zip Code Home Phone: ( ) Cell Phone: ( ) Add: Do you prefer to receive calls: ( ) Yes ( ) Home ( ) Work ( ) Cell phone ( ) No Birth Date: / / Age: ( ) Single ( ) Married ( ) Minor Patient s Employer: Work Phone: ( ) Employer Address: Street City State Zip Code Spouse or Parent/Guardian s Name: Phone: ( Person to contact in case of emergency: Phone: ( ) ) Whom may we thank for referring you? INSURANCE INFORMATION Primary Insurance: ID #: Name of Principal Card Holder: Birth Date: / / Last First MI Relationship to patient ( ) Self ( ) Spouse ( ) Parent Secondary Insurance: ID #: Name of Principal Card Holder: Birth Date: / / Last First MI Relationship to patient ( ) Self ( ) Spouse ( ) Parent AUTHORIZATION AND RELEASE I authorize release of any information concerning my (or my child s) healthcare, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me directly to the doctor. Signature of Patient (Parent/Guardian) / / Date 1
2 PRIME CARE PHYSICAL THERAPY NEW PATIENT HEALTH QUESTIONNAIRE - BALANCE Patient Name: Date of Birth: / / What is your complaint? ( ) dizziness ( ) spinning sensation Check all that applies ( ) woozy / cloudy sensation ( ) imbalance ( ) walking ( ) standing ( ) when doing usual daily activities ( ) difficulty focusing ( ) when reading ( ) when looking at something What medication/s are you currently taking / have you tried for your dizziness? Rate the following activities as it is affected by your problem: Use this scale to rate each activity 0 = not affected 3 = severely affected 1 = mildly affected NA = not applicable 2 = moderately affected Bed mobility (laying down, getting up, turning over) Transfer and turning activities (sit to stand, bending over, turning head / body) Walking (indoor, outdoor, in the dark, on carpet, ramps, stairs, on uneven surfaces) Shopping (checking grocery items while walking, walking in the mall / open space) Household chores Self care activities (bathing, dressing up, grooming) Driving / Passenger in a vehicle (checking traffic, reading signs) Transportation (as a passenger in a vehicle) Reading (book, newspaper, in front of the computer) Social (going out for leisure activities, meeting with people) Cognitive (ability to think and concentrate) Work/School: indicate nature of work/school activity Other activities you want your clinician to know: 2
3 Patient Name: Date: MEDICAL HISTORY Check if you ever had the following: ( ) AIDS/HIV ( ) Cancer ( ) Heart Disease ( ) Migraine ( ) Arthritis ( ) Diabetes ( ) Hernia ( ) Pacemaker ( ) Asthma ( ) Dizziness ( ) High/Low Blood Pressure ( ) Sinus Problem ( ) Back / Neck Pain ( ) Epilepsy ( ) Joint Replacement / Surgery ( ) Sleep problem ( ) Blood Transfusion ( ) Fibromyalgia ( ) Leg/knee pain Check if you currently have / have history of the following ear symptoms: ( ) ringing / buzzing ( ) Right ( ) Left ( ) Both ( ) pressure / clogged sensation: ( ) Right ( ) Left ( ) Both ( ) difficulty hearing ( ) Right ( ) Left ( ) Both 3
4 Patient Name: Date: DIZZINESS HANDICAP INVENTORY This 25 - item questionnaire will help your therapist to identify the difficulties you may be experiencing because of your vertigo, dizziness or unsteadiness. Please check your appropriate answer for each question. If your symptom is better now, answer the questions based on when your symptom was still active. YES NO SOMETIMES P 1. Does looking up increase your problem? ( ) ( ) ( ) E 2. Because of your problem, do you feel frustrated? ( ) ( ) ( ) F 3. Because of your problem, do you restrict your ( ) ( ) ( ) travel for business or recreation? P 4. Does walking down the aisle of a supermarket ( ) ( ) ( ) increase your problem? F 5. Because of your problem, do you have difficulty ( ) ( ) ( ) going into or out of bed? F 6. Does your problem significantly restrict your ( ) ( ) ( ) participation in social activities such as going out to dinner, movies, dancing or parties? F 7. Because of your problem, do you have difficulty ( ) ( ) ( ) reading? P 8. Does performing more ambitious activities like ( ) ( ) ( ) sports, dancing, household chores such as sweeping or putting away dishes increase your problem? E 9. Because of your problem, are you afraid to leave ( ) ( ) ( ) home without having someone accompany you? E10. Because of your problem, have you been ( ) ( ) ( ) embarrassed in front of others? P11. Do quick movements of your head increase ( ) ( ) ( ) your problem? F12. Because of your problem, do you avoid heights? ( ) ( ) ( ) 4
5 YES NO SOMETIMES P13. Does turning over in bed increase your problem? ( ) ( ) ( ) F14. Because of your problem, is it difficult for you to do ( ) ( ) ( ) strenuous house or yard work? E15. Because of your problem, are you afraid people might ( ) ( ) ( ) think you are intoxicated? F16. Because of your problem, is it difficult for you to go ( ) ( ) ( ) for a walk? P17. Does walking down a sidewalk increase your problem? ( ) ( ) ( ) E18. Because of your problem, is it difficult for you to ( ) ( ) ( ) concentrate? F19. Because of your problem, is it difficult for you to walk ( ) ( ) ( ) in the dark? E20. Because of your problem, are you afraid to stay home ( ) ( ) ( ) alone? E21. Because of your problem, do you feel handicapped? ( ) ( ) ( ) E22. Has your problem placed stress on your relationship ( ) ( ) ( ) with members of your family or friends? E23. Because of your problem, are you depressed? ( ) ( ) ( ) F24. Does your problem interfere with your job or ( ) ( ) ( ) household responsibilities? P25. Does bending over increase your problem? ( ) ( ) ( ) **This part to be completed by your therapist Yes = 4 Functional Scale = / 36 Sometimes = 2 Emotional Scale = / 36 No = 0 Physical Scale = / 28 TOTAL SCORE = / 100 5
6 Patient Name: Date: ACTIVITIES-SPECIFIC BALANCE CONFIDENCE SCALE (ABC Scale) For each of the following, please indicate your level of confidence in doing the activity without losing your balance or becoming unsteady by choosing one of the percentage points on the scale from 0% to 100%. If you do not currently do the activity in question, try and imagine how confident you would be if you had to do the activity. If you normally use a walking aid or you had to hold on to someone to do the activity, rate your confidence as if you were using these supports. 0% % No confidence Completely confident How confident are you that you will not lose your balance or become unsteady when you 1. walk around the house? % 2. walk up or down the stairs? % 3. bend over and pick up a slipper from the front of the closet? % 4. reach for a small can off a shelf at eye level? % 5. stand on tiptoes and reach for something above your head? % 6. stand on a chair and reach for something? % 7. sweep the floor? % 8. walk outside the house to a car parked in the driveway? % 9. get into or out of a car? % 10. walk across a parking lot to a mall? % 11. walk up or down a ramp? % 12. walk in a crowded mall where people rapidly walk past you? % 13. are bumped into by people as you walk through the mall? % 14. step onto or off an escalator while holding onto parcels such that you cannot hold onto the railing? % 15. walk outside on icy sidewalks? % 6
7 AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION Patient Name: Date of request: / / Address: Street City State Zip Code Date of birth: / / As required by the Privacy regulations, this practice may not use or disclose your protected health information except as provided in our Notice of Privacy Practices without your authorization. I hereby authorize this office and any of its employees to use or disclose my patient health information to the following persons: (you may write doctor s name and/or family member s name) Patient Health Information to be disclosed: (check all that applies) ( ) Physical therapy reports ( ) Medical tests ( ) Others: Effective dates for this authorization: / / to / / (you may use date of initial visit as your start date and authorization can end up to one year from start date) Signature of Patient / Authorize Representative 7
8 ASSIGNMENT OF BENEFITS / RIGHTS FOR DIRECT PAYMENT TO PROVIDER (Private, Group Accident & Medicare health Insurance) I hereby instruct and direct Insurance Company to pay by check made Primary Insurance Name out and mail directly to: PRIME CARE PHYSICAL THERAPY, P.C Route 17M Goshen, NY for professional or medical expense benefits allowable, and otherwise payable to me under my current insurance policy as payment toward the total charges for professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above named assignees, and I have agreed to pay my balance of said professional services charges over and above this insurance payment. I also understand and agree that I am ultimately responsible for all fees including reasonable collection costs. This assignment of benefits does not release me from my obligation to pay professional fees. A PHOTOCOPY OF THIS ASSIGNMENT SHALL BE CONSIDERED AS EFFECTIVE AND VALID AS THE ORIGINAL. I authorize release of any information pertinent to my case to any insurance company, Health Care Financing Administrator, adjustor or attorney involved in this case. Signature of Patient / Authorized Representative / / Date Name of Patient / Authorized Representative 8
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A) PATIENT INTAKE/TREATMENT FORM 1) Patient Name: 2) Social Security #: 3) Home Phone number: ( ), Cell: ( ), Work: ( ) 4) Address: City, State, Zip Code 5) Gender: Male Female 6) Date of Birth (DOB):
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21 ST CENTURY REHAB, PC INDIANOLA PATIENT INFORMATION FORM Please print and complete ALL items. If an item does not apply, insert N/A. PATIENT LEGAL NAME: SEX: LAST FIRST INITIAL ADDRESS: STREET CITY STATE
Are you currently pregnant? ( ) Yes, due date: ( ) No ( ) Unsure
Patient s Full Name: of Birth: Age: Address: City: State: Zip: Patient Social Security #: Gender: Height: Weight: Cell Phone: Other Phone: E-Mail: Preferred appointment reminder: ( )Text: Cell Phone Provider:
Integrated Spinal Solutions Patient Information
Integrated Spinal Solutions Patient Information Patient Name: City/State/Zip: Today s Date: Home Telephone: Work Telephone: Birth Date: Age: Cellular Telephone: Height: Weight: Employer s Name: Social
Christos Vasakiris, D.C.,D.A.C.A.N. 350 West Montauk Highway Lindenhurst, N.Y, 11757
Christos Vasakiris, D.C.,D.A.C.A.N. 350 West Montauk Highway Lindenhurst, N.Y, 11757 PLEASE PRINT Patient Name SS# Address City State Zip Code Birth Date / / Age Circle one: Marital Status: S/M/D/W/P How
HIPAA Authorization Release Form
HIPAA Authorization Release Form I,, give permission to all my health care and medical services providers and payers to disclose and release my protected health information described below to: Name(s):
List any past surgeries that you have had throughout your lifetime (if none, circle NONE):
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
LAWRENCE J. FINKEL, M.D., P.C. 360 CHURCH STREET WARRENTON, VA (540) PHONE (540) FAX
LAWRENCE J. FINKEL, M.D., P.C. 360 CHURCH STREET WARRENTON, VA 20186 (540) 347-2020 PHONE (540) 341-7980 FAX www.finkelderm.net Dear Patient: Welcome to our Practice. We have you scheduled for your first
PATIENT INFORMATION. Social Security Number: - - Home Phone: ( ) Work Phone: ( ) Cell: ( ) Nearest Relative: Phone: ( ) Employer Address:
PATIENT INFORMATION PERSONAL INFORMATION Today s Date: Check the type of care desired: Temporary Relief Lasting Correction Name: Social Security Number: - - Date of Birth: - - Age: Height: Weight: Check
Have you had Chiropractic Care Before? When? Where? What is your current complaint (be specific)?
Welcome to Rizzo Chiropractic Holistic Health and Wellness Center Check the following services you are interested in: Chiropractic Physical Rehabilitation Nutritional Analysis (Hair, Blood & Urine) Detox
Medical Information Sheet
Medical Information Sheet Name: Date: Age: Sex: M F Height: Weight: Dominant hand: R L Occupation: Presently working: Y N Reason for being seen today: Date of Onset: Involved side: R L Both Describe any
Insurance Information
New Patient Registration - Brunswick Physical Therapy, PLLC Patient Name: DOB: M[ ] F[ ] Social Security # (last 4 digits): [ ]Single [ ]Married [ ]Widowed [ ]Other Address: City: State: Zip Code: Home
New Patient Referral and Insurance Verification Form
New Patient Referral and Insurance Verification Form Today s Date: Prior Patient: Y N How did you hear about our practice? Physician: Dr., Internet:, Family/Friend:, Advertising:, Insurance:, Other:. Patient
Today's Date First Name Middle Name/Initial Last Name. Full Part Not a Student Marital Status Circle One
WELCOME TO SUPERIOR PHYSICAL THERAPY Please help us serve you better by taking a few minutes to provide the following information PLEASE PRINT Your physician has prescribed a series of therapy treatments
PATIENT INFORMATION DATE NAME PREFERRED NAME: LAST FIRST MI
PATIENT INFORMATION DATE NAME PREFERRED NAME: LAST FIRST MI BIRTH DATE MARRIED SINGLE MINOR MALE FEMALE MONTH DAY YEAR SOCIAL SECURITY # ADDRESS STREET APT. # CITY STATE ZIP I would like my appointments
Caritas Medical Center, LLC
Caritas Medical Center, LLC KIDNEY DISEASE AND HYPERTENSION SPECIALIST 105 NORTH PARK TRAIL SUITE 300 STOCKBRIDGE, GA 30281 OFFICE: 678 284 0800 FAX: 678 284 9299 WWW.CARITASMED.COM DR. LEO OVADJE DR.
Patient Information. Health Information
Patient Information Patient Name: Date: Last First MI (Preferred name) Male Female Married Single Child Other Social Security #: Birth Date: Phone (Home): (Work): Ext: Cell: Email: Address: Street Apartment
Name: Date of Birth: Age: Sex:
PATIENT INFORMATION Name: Date of Birth: Age: Sex: Address: (Cit, State, Zip) Billing Address: SSN: Primary Phone #: Work Phone #: Secondary Phone #: Email: Referring Physician: Employment: Full/Part/None
Olde Naples Chiropractic Health Center
Patient Full Name: E-Mail Address: Mailing Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Emergency Contact Name/number: Occupation: Status: Employed Full Time Student Part Time Student
Germantown Smiles,PC Germantown Road Suite 225 Germantown, Maryland
Germantown Smiles,PC 19735 Germantown Road Suite 225 Germantown, Maryland 20874 240-654-3302 Patient Information Patient Name: Last First MI Gender: Male Female Family Status: Married Single Child Other
Patient Registration Form
PATIENT INFORMATION Patient Name: of Birth: Age: Marital Status: Married Single Home Phone: Email: Address: Cell: SS#: Divorced Patient Registration Form Account Number: Gender: Widowed Separated Unknown
New Patient Registration
New Patient Registration Patient Information: Name (Last, First): Date: Address: Street City State Zip Code Phone (Home): (Work): (Cell): Social Security Number: - - Birth Date: / / Sex: ( M / F ) Email:
Address. City/State/Zip. Marital Status: S M D W Sex: M F Date of Birth / / Age. Primary Phone Secondary Phone. Employer PARENT/GUARDIAN
PATIENT INFORMATION First Name M.I Last Name Address City/State/Zip SSN.#_ Marital Status: S M D W Sex: M F of Birth / / Age Primary Phone Secondary Phone Employer Email PARENT/GUARDIAN Name of Birth /