Patient Intake Packet

Today's Date:

Date

Patient Name:*

Sex:*

DOB*

Phone:

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Soc. Sec. #:

Type of Insurance:*

ID#:*

Subscriber:

Name of Insured (if not patient):

Relationship:

Subscriber DOB:

Height:

Weight:

Phone (home):

Cell:

Email:

example@example.com

Would you like to receive email appointment reminders?

YESNO

Mar. Status:

Occupation:

Employer:

FT

FTPTRestricted Duty

Out of Work? (since:)

Date

Emergency Contact:

Phone Number

Area CodePhone Number

Primary Care Physician?

Referring Physician

Complaint/injury:*

Have you had physical therapy for any reason this year?

YESNO

If yes, please explain:

How did you hear about us?

Were you injured while at work? (If yes, complete the following questions. )

Have you received prior treatment?

Date of injury:

Date

Phone number:

Workman's Compensation Insurance Agent:

If yes, name of physician:

Claim #:

Name of Attorney (if applicable):

Address:

Dates out of work: From

Date

Dates out of work: To

Date

Automobile accident? (If yes, complete the following questions.)

Date of accident:

Date

Have you received prior treatment?

Automobile Insurance Carrier:

If yes, name of physician:

Name of adjuster:

Name of attorney (if applicable)

Address:

Phone:

State accident occurred in?

Dates out of work: From

Date

Dates out of work: To

Date

Who was at fault?

Name:

Do you have high blood pressure?

YESNO

Do you have heart disease?

YESNOOther

Do you have a pacemaker?

YESNO

Do you experience angina (chest pains) at rest or with exercise?

YESNO

Do you experience shortness of breath?

YESNO

Do you have lung disease?

YESNO

Do you have asthma or any known allergies?

YESNO

Do you have heartburn, stomach, and/or intestinal upset?

YESNO

Do you have a thyroid condition? If yes, explain below.

YESNO

Explain:

Have you been diagnosed with diabetes?

YESNO

Have you been diagnosed with cancer?

YESNO

If yes, describe:

Do you have low blood sugar?

YESNO

Have you experienced recent weight gain/loss?

YESNO

Do you have osteoporosis?

YESNO

Have you experienced an increase in frequency or intensity of headaches?

YESNO

Do you have any unusual join pain or swelling?

YESNO

Do you have a history of fractures?

YESNO

Do you have impaired vision?

YESNO

Do you have impaired hearing?

YESNO

Have you had any complicated pregnancies?

YESNO

Do you have dysmenorrhea (abnormal menstrual cycles?

YESNO

Are you now, or do you have any reason to believe you may be pregnant?

YESNO

Please list all medications and dosages

Please list all surgeries and approximate dates

Please indicate diagnostic tests for this problem:

Have you seen anyone else for your current problems?

Signature:

Date:

Date

The following are our office polocies governing patient care. Please read carefully and inital each policy signifying your understanding and agreement to abide by said policies.

Appointment Scheduling. We will strive to provide you with effective, efficient treatment and accommodate your needs to the best of our ability. To be fair to all of our patients, we ask that cancellations be made 24 hours in advance, and if you are going to be late for your appointment, please call and let us know. Adherence to the recommended plan of care and consistency with appointment attendance is vital to your progress. Please make every effort to follow this plan. Lastly, if you miss more than 3 appointments, without prior notification, we reserve the right to discontinue your therapy to open the schedule to new patients. Thank you for your cooperation regarding these policies.

Consent to Treatment. I voluntarily consent to physical therapy evaluation and treatment as prescribed by my attending physician or his/her designee as necessary, under the direction of a registered physical therapist/physical therapist assistant. Further, I acknowledge that no guarantee has been or can be made as to the results of such treatments.

Privacy Practices Acknowledgment. We are very concerned about protecting your privacy, especially in matters that concern your personal health information. In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), we are required to provide you with a copy of our privacy policies and procedures. We encourage you to read this document carefully, for it outlines the use and limitations of the disclosure of your health information and your rights as a patient. If you ever have any questions or concerns regarding the use of dissemination of your personal health information, we would be happy to address them. By initialing this section, I, the undersigned, acknowledge that a copy of Cape Coastal PT Notice of Privacy Practices for Protected Health Information has been made available to me.

Assignment of Benefits. In consideration of agreement between Cape Coastal PT and myself to provide me with physical therapy services, I hereby irrevocably assign to Cape Coastal PT my right, title, and monetary interests in, and to all, insurance benefits to which I may be entitled to. Assignment of such benefits is limited to the extent of the amount of the cost of all services to me. I hereby authorize all payment for services provided by Cape Coastal PT to be paid directly to Cape Coastal PT that may be due upon receipt of claims or itemized statements for services rendered.

Billing / Information Release. I authorize Cape Coastal PT to furnish all necessary parties any information it may have regarding my condition while under observation or treatment deemed necessary to facilitate reimbursement for services rendered. I acknowledge that Cape Coastal PT is duly authorized such rights in accordance with all federal and state confidentiality laws.

Responsibility of payment. I, the undersigned, acknowledge full financial responsibility to Cape Coastal PT for any and all charges not covered by my insurance policy. This includes all copay's, deductibles, or charges that are denied payment by my insurance company for services rendered.

I certify that I have read, understand, and agree to abide by all office policies listed above.

Patient Signature

Date

Name (please print)