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Welcome! And thank you for choosing Advanced Physical Therapy, Inc. Our mission is to offer you the highest quality care in a comfortable, efficient and safe manner. Your appointment is on at with. From Huguenot/Courthouse Rd Take Midlothian Turnpike West (60W) Go 1.5 Miles Turn left onto N. Woolridge Rd. Turn left at the first traffic light (Walton Park Rd.) From Powhite Parkway (Rt. 76) Take Midlothian Turnpike West (60W) Go 5.2 Miles Turn left onto N. Woolridge Rd. Turn left onto Walton Park Road From 288 (Brandermill/Woodlake) Take Woolridge Road North Go 2 Miles (to the 3rd traffic light) Turn right onto Walton Park Rd. From 288 (West End) Take Woolridge Road North Go 2 Miles (to the 3 rd traffic light) Turn right onto Walton Park Rd.

NAME: First M.I. Last ADDRESS: Street City State Zip HOME PHONE: CELL PHONE: E-MAIL: Would you like to receive our newsletter by E-mail? yes / no SOCIAL SECURITY NUMBER: BIRTH DATE / / MARITAL STATUS < > MALE < > FEMALE EMPLOYER: WORK PHONE EXT. PARENT OR RESPONSIBLE PARTY (if different than patient) HOW DID YOU HEAR FROM ADVANCED PHYSICAL THERAPY? (Friend? family member?) SPOUSE/GUARDIAN INFORMATION HIS/HER NAME CELL PHONE EMPLOYER WORK PHONE EXT BIRTH DATE / / SOCIAL SECURITY NUMBER HOME PHONE INSURANCE INFORMATION PRIMARY INSURANCE INSURANCE ADDRESS NAME OF INSURED INSURED S DOB INSURED S ID # GROUP # EMPLOYER S NAME RELATIONSHIP TO PATIENT WORKERS COMPENSATION/ ACCIDENT INFORMATION SECONDARY INSURANCE INSURANCE ADDRESS NAME OF INSURED INSURED S DOB INSURED S ID # GROUP # EMPLOYER S NAME RELATIONSHIP TO PATIENT WC CONTACT NAME PHONE # FAX # INSURANCE COVERAGE CLAIM # ACCIDENT DATE / / ACCIDENT TIME DATE OF ONSET OF SYMPTOMS / / PLEASE DESCRIBE ACCIDENT IS AN ATTORNEY INVOLVED? < > YES < > NO PERSONAL INFORMATION NAME OF ATTORNEY FIRM ADDRESS I,, consent to treatment by Timothy J. Wittenauer, MSPT, CFMT, his designees, assistants, and staff. Recognizing that I have a condition requiring medical care and further acknowledge that I am aware and affirm that no guarantees have been made to me concerning treatment by ADVANCED PHYSICAL THERAPY, INC., I hereby instruct the above named Insurance Company to pay by check made to and mailed directly to ADVANCED PHYSICAL THERAPY, INC. Patient s Signature: Date: Primary Doctor: Referring Doctor:

TO OUR PATIENTS PLEASE READ AND SIGN Our Cancellations and No Show Policy: We take this subject seriously at the clinic, because it can make a difference between whether you succeed in our treatment or not. Your referring doctor and/or your therapist has prescribed a set frequency of treatment. There is a $50 charge for a cancellation without a 24 hour notice. This charge will not be covered my insurance or worker s compensation. You will be responsible for this fee. Regarding Insurance: We accept most major insurance plans, but you are responsible for checking with your carrier to see if services at our office will be covered. We do not participate with any Medicaid-HMO plans. We may accept assignment of insurance benefits; however we do require that all co-payments be made at the time of service. The balance is your responsibility whether your insurance company pays or not. It is your responsibility to notify us of any changes in your policy information. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. Please be aware that some, and perhaps all, of the services provided may be non-covered and not considered reasonable and necessary under the Medicare Program and/or other medical plans. You will be responsible for these balances. Additionally, it is your responsibility to obtain and track referrals for your visits. Initial Commitment to make Co-Payment: In order to comply with your health insurance company s rules and regulations, you must pay your contracted co-pay at the time services are rendered. For your convenience, Advanced Physical Therapy, Inc. accepts cash, checks, credit cards and money orders. If you are seen by the physical therapist and do not pay your co-pay, a $5.00 service fee may be added to your bill. Patient Remainder Statements: Upon Advanced Physical Therapy, Inc. s payment/response from your insurance company, and at each of your visits, our Front Desk Administrator will furnish you a Patient Remainder Statement. This is our primary billing format. This statement shall reflect all amounts due from you at that time, including any co-pays, co-insurance, deductibles, and all other charges. Upon receipt of the Patient Remainder Statement, you are required to make a payment. If there are any amounts in dispute, please contact our business office immediately. If there is a discrepancy or dispute in the amount paid by you insurance company, it is your responsibility to contact the insurance carrier and resolve it. Minor Patients: The adult accompanying or responsible for a minor and/or the parents (or guardians of the minor) are responsible for full payment, including all cancellation and no show charges. Return Check Fee: Any returned checks will result in a returned check fee of $50. Our company is charged a fee for any returned checks and that fee must be reimbursed by the patient. Future payments must be made by cash or credit card. Collection Fees: In the event that your account is turned over to a collection agency, you will be responsible for all collection costs including reasonable attorney fees. You and the HIV Virus: We are all concerned with minimizing the risk of exposure to the HIV virus. We have very careful protocols that comply with government regulations for safety (monitored by the Occupational Health and Safely Administrations). We would like you to know that you are at no time exposed to blood or bodily fluid of any other patient. We are obligated to provide a safe workplace. There may be occasion when we are accidently in contact with your blood or other bodily fluids. Virginia Law authorizes that if such an incident occurs, we may require that you have your doctor test your blood for HIV. The same law requires that you be informed of this. These are precautions are taken in the interest of safety for you and our staff. Release of Information: If your insurance company requires medical reports to document your treatment and progress, your signature below authorizes the release of medical information necessary to process your claim. _ Attire for Physical Therapy: Shorts or sweatpants with elastic waistband may be ideal particularly if we are treating the lower extremities. Loose fitting clothing (a sports bra for women) is recommended for treatment of the upper extremities. You may feel free to bring your attire for physical therapy and change at our office. Just arrive early for your appointment to allow time to change. Please wear or bring clean socks as clean socks are required to be worn in the clinic. Signature of Patient or Responsible Party Date

Initial Evaluation Form Name Date Referring Doctor: Family Doctor: Occupation Work Status (circle one): Full Time; Part Time; Retired: Not Working due to injury (date last worked ). I. Chief Complaint: List the nature of each symptom, its location, and its pain range on a 0-10 scale (0=no pain, 10=most severe pain you have experienced). Please use one or more of the following descriptors or one of your own to describe the nature of your symptoms (sharp pain, stabbing, radiating, throbbing, dull ache, numb, burning, tingling, hot, cold, weakness). Nature (ie, sharp pain) Location (ie, R knee) Pain Range (0-10) A. B. C. D. E. Please shade in area or areas where you are experiencing symptoms. Please label the areas using the letters A, B, C, D, and/or E, that correspond with the above table.

II. Current Symptoms: A. Date pain / injury started (onset): B. How pain / injury started: C. How often do you experience symptoms: Constantly (76-100%) Frequently (51-75%) Occasionally (26-50%) Intermittently (0-25%) D. Have your symptoms: become worse become better remained the same E. What makes your symptoms worse: sitting standing bending lifting walking running other Please specify: F. What relieves your symptoms: G. Progression through day (circle): Awakening = better / worse Midday = better / worse End of day = better / worse H. How much does your pain interfere with your activities (please mark and list activities): 1. Daily 2. Extra-curricular none (1-20%) rarely (20-40%) often (40-60%) most of the time (60-80%) always (80-100%) I. Functional Score: (note: your therapist will fill in this line) III. Intervention for current episode and date(s): A. Who have you seen for these symptoms: Physical Therapist, date(s): Massage Therapist, date(s): Chiropractor, date(s): Neurologist, date(s): Orthopedist, date(s): Other Specialist, date(s): B. What tests have you had for these symptoms: X-ray, date(s): MRI, date(s): CT Scan, date(s): EMG, date(s): Other, date(s): C. Have you had surgery for these symptoms: Yes / No. If yes, type of: IV. Past history of symptoms: A. Have you ever had these kinds of symptoms before: Yes / No. If yes, when: B. How often have they reoccurred: C. Have your symptoms increased in their: Frequency: Yes / No; Severity: Yes / No

V. Past Medical Symptoms A. Please check any condition listed below that applies to you: ( ) none of these apply ( ) Asthma ( ) bronchitis ( ) emphysema ( ) Shortness of breath ( ) chest pain ( ) Coronary heart disease ( ) angina ( ) Pacemaker ( ) High blood pressure ( ) Heart attack ( ) heart surgery ( ) Stroke ( ) TIA ( ) Congestive heart disease ( ) Blood clot ( ) emboli ( ) Epilepsy ( ) seizures ( ) Infectious diseases ( ) Severe headaches ( ) frequent headaches ( ) Vision difficulties ( ) hearing difficulties ( ) dizziness ( ) fainting ( ) bowel problems ( ) bladder problems ( ) weight loss ( ) energy loss ( ) diabetes ( ) hernia ( ) any pins or metal implants ( ) currently pregnant ( ) Cancer ( ) chemotherapy / radiation ( ) Osteoporosis ( ) Long term steroid usage ( ) Are you a current smoker? Y / N Have you ever smoked in the past? Y / N If yes to either question, how many packs? for how many years? Please explain any condition that you have marked above: B. Please list ALL current prescription or non-prescription medications and include name of medication, dosage, frequency, and route of administration (example 50mg tablet) (OR bring a printed list of medications supplied by your pharmacist or physician): C. List ALL previous surgeries and dates: D. List previous accidents or injuries and dates: E. List previous physical therapy or bodywork (i.e., chiropractic, massage, acupuncture) and dates: Medicare Patients Only: 1. Have you hade 2 or more falls in the past year? Yes / No 2. Have you had a fall that resulted in an injury in the past year? Yes / No 3. Height: Weight: VI. Physical Therapy Goals (what would you like to get out of physical therapy?) A. B. C. D.

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