GIVE US STRENGTH PHYSICAL THERAPY

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GIVE US STRENGTH PHYSICAL THERAPY Thank you for choosing Give Us Strength Physical Therapy for your rehabilitation needs. PATIENT INFORMATION: Name (Last, First, Middle Initial): DOB: Social Security Number: Sex: Male Female Marital Status: Single Married Email: Mailing Address: City State Zip Home phone: Cell Phone Employer: Occupation: Employer Phone: Employer Address: Emergency Contact: Relation to you? Phone: Preferred Method of Appointment Reminders: Text Email How did you hear about us? Doctor Friend/Family Internet Other (Describe): RESPONSIBLE PARTY (If different from Patient): Name: (Parent/Guardian) Address: Phone: PHYSICIAN INFORMATION: Referring Physician: Primary Physician: INJURY INFORMATION: Type: Work Auto Sport Other Name of Auto Insurance (If Auto Accident): Date of injury: Claim # Place of Injury Brief description of Injury: *If Workers Comp: Case Workers Name: INSURANCE INFORMATION Primary Ins: Subscriber Name: Date of Birth: Policy #: Group #: For Military/TRICARE patients: Sponsor s Social Security #: Sponsor DOB: Secondary Ins: Subscriber Name: Date of Birth: Policy #: Group # No Insurance: Pay at time of service unless prior arrangements have been made.

Consent for Treatment, Billing Agreement and Privacy Policies Information for patients without insurance: If you do not have insurance coverage, you will be expected to pay for your bill, in full at the time of service, or make payment arrangements with one of our administrative staff members. For your convenience we accept cash, checks, major credit cards and debit cards. Information for patients with insurance: Insurance coverage is a contract between you, your insurance company, and in many instances your employer. As a courtesy to you, we will file your medical claim with your insurance company in a timely manner. In most instances, we will accept payment directly from your insurance company in accordance with your policy s terms and apply the payment to your account. Contractual discounts will be applied at that time. You are responsible for any co-payment, co-insurance, or deductible. Co-pays are expected at the time of service. Even though we provide you with the most up to date information about your benefits, ultimately, you are expected to know your co-pay and deductible amounts. You will receive periodic statements indicating that we have billed your insurance company on your behalf. However, you are ultimately responsible for payment of your physical therapy services. If your insurance company fails to pay your claim in a timely manner, or rejects your claim in part or in full, you are personally responsible for, and will be billed directly for the services you received. If that happens you may want to contact your insurance company directly or your insurance plan administrator at your place of employment to discuss the reason for the denial of benefits. We accept cash, personal checks, Visa, Mastercard and discover **There is a returned check processing fee of $25 per occurrence** MISSED APPOINTMENT POLICY: Our priority is quality patient care. We are very dedicated to you, and are determined to help as much as we can. In order for us to better assist you in achieving your desired results, compliance to your scheduled appointment times are strongly encouraged. Our time is also very valuable to assisting other patients. We understand there may be times when you miss an appointment due to illness, obligations to work or family and emergency situations. However, we urge you to call 24-hours prior to cancelling your appointment. Not following this policy or if there is a no-show to a scheduled appointment a $75.00 cancellation fee will be assessed. Please understand that if you no-show for 2 consecutive appointments, no show for 3 appointments, or cancel for a total of 3 appointments, you may be discharged from care. We will notify you in writing, via mail, if you are discharged from care. HIPPA/PRIVACY POLICY: We are required by law to maintain the privacy of your health information and provide you with a copy of our Privacy Policy. Specifically HIPPA and Give Us Strength s Privacy Policy individually identify you and relate to (1) your past, present, or future physical or mental health; (2) related healthcare services; or (3) your past, present or future payment for your healthcare. Under no circumstances is your private healthcare information given to anyone unless your consent is given. If you wish for someone to be authorized to assist you with your care at Give Us Strength Physical Therapy, written consent will be needed. We may use health information about you to provide, coordinate or manage your healthcare and related services. We may disclose health information about you to your doctor, staff or others who are involved in taking care of you and your health. For example, your doctor may be treating you for a heart condition, which we may need to know about to determine the best plan of care. If you have further questions about our HIPPA or Privacy Policy we have a copy at the front desk. *I have read and agree to the terms of this statement. *I consent to receive Physical Therapy care at Give Us Strength Physical Therapy. Signature of Patient/Guardian Printed Name of Patient Date

GIVE US STRENGTH PHYSICAL THERAPY PATIENT S NAME DATE OF BIRTH CHIEF CONCERN DATE OF INJURY LAST DOCTOR S VISIT USING THE 0-10 SCALE WITH 0 BEING NO PAIN AND 10 BEING THE WORST PAIN IMAGINABLE PLEASE CURRENT LEVEL OF PAIN: /10 THE BEST YOUR PAIN HAS BEEN IN THE LAST 2 DAYS: /10 THE WORST YOUR PAIN HAS BEEN IN THE LAST 2 DAYS: /10 CURRENT MEDICATIONS Drug allergies: No Yes To what? Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements: Name of drug Dose (include strength & number of pills per day) How long have you been taking this? 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Please List Any Surgeries or other conditions for which you have been hospitalized: 1. 2. 3. Please indicate if you have received any of the following for the current injury: General Practitioner Physiatrist (Pain Doctor) Massage Therapy Orthopedic Surgeon Chiropractor X-Ray Neurosurgeon Physical Therapy CT Scan Neurologist Occupational Therapy MRI Myelogram EMG / NCV (Nerve Testing) Emergency Room

GENERAL MEDICAL HISTORY: SYSTEMS REVIEW Please indicate if you have been treated for or experienced any of the following: Fatigue Recent Weight Change; How much lbs. Night Sweats/Fevers CARDIOVASULAR High Blood Pressure Chest Pain/Angina Coronary Heart Disease Heart Surgery/Pacemaker MUSCULOSKELETAL Muscle Pain/Cramps Stiffness Joint Pain or Swelling Osteoporosis RESPIRATORY Shortness of Breath Excessive Coughing/Sputnum Asthma Bronchitis Emphysema NEUROLOGICAL Severe or Frequent Headaches Epilepsy/Seizures Numbness or Tingling Dizziness or Fainting Weakness CVA (Stroke)/TIA (Mini Stroke) Huntington s Traumatic Brain Injury Muscular Dystrophy Fibromyalgia GASTROINTESTINAL/URINARY Nausea/Vomiting Abdominal Pain Rectal Bleeding Blood in Urine Kidney Stones ENDOCRINE Excessive Thirst/Urination Thyroid Dysfunction/Goiter Hormone Problem(s) Diabetes HEMATOLOGICAL/LYMPHATIC Bruise Easily Slow to Heal Enlarged Glands OPHTHALMOLOGICALY Glasses/Contacts Blurred/Double Vision Eye Disease/Injury Glaucoma EAR-NOSE-THROAT Hearing Loss or Ringing Sinus Problems Difficulty Swallowing Voice Change ALLERGIES Food and Medical Allergies OTHER Pregnant Breast Pain/Discharge Menstrual Changes Blood Clot/Emboli Confusion/Memory Loss Tobacco Diabetes Type 1 Diabetes Type 2 HIV/AIDS Tuberculosis Cancer/Chemotherapy/Radiation Depression Unexplained Weight or Energy Loss Other (Explain):

GIVE US STRENGTH PHYSICAL THERAPY Acknowledgement of Receipt of Notice of Privacy Practices 1. I have received/been offered a copy of Give Us Strength Physical Therapy s Notice of Privacy Practices. 2. I agree to the open treatment area used by Give Us Strength Physical Therapy and understand that a private treatment may not be available. 3. I agree and understand that other patients will be completing treatment plans during my visit and may overhear information regarding my plan of care. 4. I agree that I must sign in at each visit. 5. I agree that a Physical Therapist/Physical Therapist Assistant student may assist in my care. 6. I agree that Give Us Strength Physical Therapy employees may call my home in regard to my health. 7. I agree that Give Us Strength Physical Therapy may use my email address to send receipts, home exercise programs, and appointment reminders. Patient/Responsible Printed Name: Date: Patient/Responsible Signature: This Section is for Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but it could not be obtained for the following reason: Individual refused to sign Communication barrier An emergency prohibited obtaining the acknowledgement Other (specify): Employee Name: Employee Signature: Date:

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