New Patient Forms

Patient Information Sheet DATE:

PATIENT#:__________________ PLEASE ANSWER COMPLETELY, PLEASE PRINT LEGIBLY

Patient Name:_______________________________________ Birth Date:____________ Age___________ Address:_____________________________________________Patient Soc. Sec. # _____________________ City: __________________________________State ___________________Zip Code:__________________ Home Phone ______________ Cell Phone ______________ Email _________________________________ Gender:

M¨ F¨

Marital Status: ¨ Single ¨ Married ¨ Divorced ¨ Separated ¨ Widowed

Patient Employed by_____________________________________________ Work Phone: _______________ Name of Insured (if other than patient) _________________________________________________________ Insured Social Security #________________________Birth Date:____________ Insured Employed by ___________________________________________ Work Phone _________________

Referring Doctor: Name:___________________________ Insurance Information: Please provide a copy of your insurance card(s). ¨ M EDICARE

(PLEASE NOTIFY US IF YOU RECEIVE ANY MEDICARE-BILLED ASSISTANCE IN YOUR HOME WHILE YOU ARE AN ACTIVE PATIENT WITH US. IF YOU DO, MEDICARE WILL NOT PAY FOR YOUR PHYSICAL THERAPY TREATMENT.)

¨ GROUP HEALTH INSURANCE ¨ WORKER’S COMPENSATION ¨ AUTO ACCIDENT Injury/Accident Information Date of accident or onset of problem ________________ In your own words, how did this injury or accident occur? ___________________________________________ __________________________________________________________________________________________ In Case of Emergency Name:____________________________________________ Relationship to Patient ____________________ Address : Home Phone ____________________ Work Phone __________________Cell Phone ____________________ Who can we thank for referring you to our practice? ¨Internet ¨Yellow Pages ¨Friend _____________ ¨ Doctor _____________________________

¨ Other___________________________________________

PLEASE USE OTHER SIDE FOR ADDITIONAL INFORMATION IF NEEDED

Performax Physical Therapy

Performax Physical Therapy PATIENT MEDICAL HISTORY QUESTIONNAIRE Name___________________________________________________________________ Date______________ 1. Right handed ¨ Left handed ¨

2. Do you smoke?

Yes ¨

3. Date of accident/Onset of problem__________________ Work ¨

No ¨

Motor Vehicle Accident ¨ Other ¨

4. How did your injury, accident, or problem occur?________________________________________________ ___________________________________________________________________________________________ 5. Have you had physical therapy this year? Yes ¨ No ¨ If yes, how many visits? ______________________ 6. Are you currently working? Occupation________________________________________ Pre-injury hours per week_____________ Current hours per week_____________ 7. Dates of worked missed due to injury _________________________________________________________ 8. Has your doctor given you any activity limitations? Yes ¨ No ¨ _________________________________ 9. Have you had any similar past injuries or ailments? Yes ¨ No ¨ Date______________________________ Please explain:____________________________________________________________________________ 10. Please list ALL SURGERIES with approximate dates:____________________________________________

11. Please list ALL CURRENT MEDICATIONS: _________________________________________________ 12. How long can you do the following WITHOUT increased symptoms? Sit_________________ Stand_________________ Walk_____________ 13. Please rate the following by marking a vertical line on each scale below. Use the scale below like a thermometer. The scale is marked mild (left) to severe (right). Place a mark on each thermometer that best describes how you feel in relation to the question next to each scale. Mild Severe Present STRESS level Pain - at its WORST Pain - at its BEST Pain - at NIGHT Pain - MOST of the time 14. Using the body diagram below, please indicate the location of any of the sensations listed. Mark the areas on the drawings with the symbol that best describes the sensations that you feel. a) +++++ Sharp Pain b) -------- Numbness c) xxxxxx Spreads to these areas

Please complete Page 2

Performax Physical Therapy 15. Do you have a FAMILY history of: Yes No ___ ___ Cancer ___ ___ Gout ___ ___ Hemophilia ___ ___ Osteoporosis ___ ___ Sickle Cell Anemia

Patient Medical Questionnaire

Page 2

Yes No ___ ___ Diabetes ___ ___ Heart Disease ___ ___ Osteoarthritis ___ ___ Psoriasis Other __________________________________

16. Have you, or do you currently have, any of the following: Yes No Yes No ___ ___ Frequent/Severe Abdominal Pain ___ ___ Speech/swallowing problems ___ ___ Appetite Change ___ ___ Anemia ___ ___ Arthritis ___ ___ Artificial Joint(s) ___ ___ Asthma ___ ___ Auto Accident (date)____ ___ ___ Back Pain ___ ___ Balance/Coordination Issues ___ ___ Bleeding problems/clots ___ ___ Blood Transfusions ___ ___ Bladder Dysfunction (urine retention, increased frequency, overflow incontinence) ___ ___ Cancer ___ ___ Chest Pain/heaviness in chest ___ ___ Diabetes ___ ___ Discolored or painful Feet ___ ___ Dizziness ___ ___ Fall ___ ___ Fainting Spells ___ ___ Fecal Incontinence ___ ___ Fracture/suspected fracture ___ ___ Gout ___ ___ Unusual growths or lumps ___ ___ Frequent/Severe Headaches ___ ___ Heart Condition(s): _____________________________________________________ ___ ___ Frequent Heartburn/Indigestion ___ ___ Changes in Hearing ___ ___ Hepatitis ___ ___ Hypoglycemia ___ ___ High Blood Pressure ___ ___ Infection/Immunosupression ___ ___ Hospitalization: ________________________________________________________ ___ ___ Swelling/redness in joint w/o injury ___ ___ Mental Lethargy ___ ___ Metal Implants ___ ___ Night Pain ___ ___ Frequent Nausea/Vomiting ___ ___ Numbness ___ ___ Constant/Severe Pain in Lower Legs ___ ___ Palpitations ___ ___ Pacemaker ___ ___ Pneumonia ___ ___ Physical Fatigue ___ ___ Current Pregnancy ___ ___ Psoriasis ___ ___ Restless/Disturbed Sleep ___ ___ Rheumatic Fever ___ ___ Seizures ___ ___ Saddle Anesthesia (loss of sensation in bowel/urinary muscles) ___ ___ Spontaneous Night Fever/Sweats ___ ___ Shortness of Breath ___ ___ Stroke ___ ___ Swelling (w/o injury) ___ ___ Tumors ___ ___ Tuberculosis ___ ___ Vision changes ___ ___ Urinary Tract Infection ___ ___ Weight Gain/Loss ___ ___ Weakness Other __________________________________________________________________________________ 17. Have you ever experienced any reaction to the following: ___ ___ Aspirin ___ ___ Latex ___ ___ Penicillin ___ ___ Steroids Other __________________________________________________________________________________ Performax Physical Therapy

(Rev 06/09)

Patient Name________________________________________ Date of Birth_____________________ Name of Insured________________________ Soc.Sec. Number of Insured______________________

Authorization to Bill Insurance (Assignment of Benefits) GENERAL CONSENT FOR PHYSICAL/OCCUPATIONAL THERAPY TREATMENT RELEASE OF MEDICAL INFORMATION

I hereby instruct and authorize payment of my physical therapy insurance benefits directly to PERFORMAX Physical Therapy toward the total charges for professional services rendered. This is A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS under this policy; this payment is not to exceed my indebtedness to PERFORMAX Physical Therapy. I have agreed to pay in a current manner any balance of said professional services, less any insurance payment. If the insurance company issues a check to me directly for services rendered by PERFORMAX, I agree that I will sign it over to PERFORMAX immediately. I also authorize the release of information and medical records to any doctor, insurance company, adjuster, or attorney involved in this case. I understand that I am responsible for: obtaining proper authorization from my insurance company, ascertaining that PERFORMAX can participate with my insurance plan, monitoring the number of approved visits, and obtaining authorization for additional visits. I understand that I am responsible for all charges regardless of what type of insurance I have. If my insurance coverage changes or terminates during the course of my treatment it is my responsibility to make sure that PERFORMAX is notified of any changes and can participate with my new plan, and I have proper authorization. It is my duty to understand any and all limits on the number of treatments or policy limits on covered procedures. I understand that if I receive treatment that is not covered under my policy, I am responsible for payment. I agree to pay any balance I owe to PERFORMAX in a reasonable and timely manner. In the event that any collection action is pursued to collect any outstanding balances, I agree to pay all costs of collection, including reasonable attorney fees, interest and court costs. I am hereby consenting to and requesting physical therapy service from PERFORMAX physical therapy to be provided by licensed physical therapist, physical therapy students, and assistants or therapists designees. My evaluation and treatment, may include but not limited to the following: observation, palpation, joint mobilization, soft tissue mobilization, modalities such as ultrasound, electrical stimulation and iontophoresis, exercise (land and/or aquatic), education and instruction, and neuromuscular techniques. I understand that no guarantees have been or can be provided regarding the success of physical therapy. In the interest of safety for all concerned, Performax Physical Therapy reserves the right to deny treatment to any individual under the influence of alcohol or drugs, or for any abusive conduct. Additional Expenses: I understand that pillows, gym balls, electrodes and other supplies are an additional cost that is separate from the cost of physical therapy treatment. Further, if I receive Iontophoresis as a treatment for my ailment, I understand that this procedure requires special electrodes, medication, and a Medical Doctor’s prescription and is an additional charge beyond the cost of other physical therapy treatment.

*_____________________________________________________________ Authorized Signature (Guardian if under 18)

Performax Physical Therapy

Date: ____________

Cancellation & No-Show Policy The following is our policy regarding appointment cancellations and no-shows. We take this subject seriously at Performax as it can make the difference between whether you succeed in your treatment or not. Usually your referring doctor and or therapist have prescribed a set frequency of treatment. Showing up as scheduled for these visits is your most important job. Other than that, all you need to do is follow your therapist’s instructions and we will be able to help you achieve your goals in treatment. ·

We require 24 hours notice in the event of a cancellation. It is your responsibility, when you call in, to have an alternative treatment time in mind that will ensure you receive the total prescribed number of treatments that week whenever possible. (In some cases, this may not work since some forms of treatment do not work well if given two sequential days.)

·

There is a $25.00 charge for a cancellation without proper notice. This charge will not be covered by insurance, but will have to be paid by you personally. (If you are here due to a Worker’s Compensation or Automobile claim, we are required to notify your adjuster/case manager and physician of missed appointments.) NOTE: If you are unable to give 24 hours notice due to conditions that you do not have control over, please notify the clinic as soon as possible and let us know.

·

You may need to see a therapist other than the one who normally treats you if you do rearrange your appointment. All of our therapists are experienced professionals, and they will study your patient chart, so you will be in good hands. You will return to your original therapist in the next regularly scheduled visit.

·

Please understand that your pain will probably increase and decrease as your course of treatment progresses and before it is finally released. Either condition can seem to be a reason not to come in: (a) you are feeling worse and think the treatment is not working, or (b) you are feeling better and it is a great day for golf. Neither of these conditions are a legitimate reasons not to come: (a) if you are in pain come in and get it fixed, (b) if you are out of pain, now is the time that we can begin doing some real correction of the underlying causes of your problem and educate you so you won’t re-injure yourself.

When a patient does not show as scheduled, three people are hurt: (1) the patient him or herself because they do not get the treatment they need as prescribed by the doctor and or physical therapist, (2) the therapist who now has a space in their schedule since the time was reserved for that patient personally, and (3) another patient who could have been scheduled for treatment if there had been proper notice. We ask for your cooperation in this regard and will have you out of pain and back to full function swiftly. We look forward to working with you.

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Patient Signature (Guardian, if patient under 18)

Date

Interviewer Signature

Date

Performax Physical Therapy

Performax Physical Therapy

Performax Front Range Physical Therapy

5920 S. Estes St. #100 Littleton, CO 80123 Phone 303-932-2500 Fax 303-932-2600

8200 E. Belleview Ave., Suite 505E Greenwood Village, CO 80111 Phone 303-741-0235 Fax 303-741-4882

Receipt of Acceptance of Notice of Privacy Practices

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. By signing this form, you are affirming that you have been made aware that we have a written Notice of Privacy Practices and you have been given the opportunity to receive a copy of our Notice.

This Receipt was signed by:

____________________________________________ Printed Name – Patient or Patient Representative ______________________________ Signature

___________ Date

_____________________________________________ Relationship to Patient (if other than Patient) Witness:

_____________________________________________ Printed Name – Practice Representative ______________________________ Signature

___________ Date