Pelvic Male Medical History Form

Pelvic Male Medical History Form
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Patient Social Security Number
Briefly describe the symptoms you are experiencing:
Onset of Symptoms (date)
Mark an X on the areas you are experiencing pain.
Pain?*

YesNo
Type of pain

achysharpdullthrobbingshootingOther
Rate pain 0-10 (0=no pain, 10 = worst imaginable):
Pelvic pressure?*

YesNo
Describe the pressure.
Urine Leakage?*

YesNo
Leakage With:

coughsneezelaughliftingexerciserunning wateron the way to the bathroomarriving homewhile pulling off pantsOther
Do you experience any of the following: (Select all that apply)

bladder urgencyfrequent urinationpain/burning with urinationdifficulty starting urinationstrain to empty bladderirregular bowel habitslose gas by accidentpain with bowel movementsstrain with bowel movements
Stool Consistency

liquidsoftfirmpellets
How long can you wait between voids?
How many bowels per day/week?
Other symptoms you would like your therapist to know about
Functional Limitations (For example: housework, childcare, driving, golfing, intercourse, work, etc)
Prior to the onset of the symptoms listed above, did you have any limitations in your functional activities?*

YesNo
If yes, please explain.
Please list any current limitations in your functional activities due to the symptoms listed above.
Employment

Part-timeFull-timeRetiredHomemakerStay-at-home-Parent
Title
Required Duties

SittingStandingWalkingDrivingRepetitive TasksLiftingCarryingOther
Allergies*

LatexRubbing AlcoholOther
Is this related to an accident?*

YesNo
Date of accident

MonthDayYear
Date
How did you hear about us?
Do you have: (Select all that apply)

history of prostate cancer and/or surgery(if you have had cancer,) have you had chemotherapy or radiationhistory of chronic prostatitishistory of sexual abuse or traumaerectile dysfunctionfrequent urinary tract infection (UTI)

Medications/Surgeries: We are happy to make a copy for you if you have a list with you. If you do not have a list, please list medications/surgeries in the following table:

	Medication	Amount (ex. 25 mg)	Frequency (ex: 2x/day)
1
2
3
4

	Surgery	Date
1
2
3
4
5
6

Past Medical History: Please select any that apply.*

Heart DiseaseDifficulty SleepingHeart AttackSkin DisorderHepatitisDizziness/BlackoutsCancerFatigueHeadachesMigraineHigh Blood PressureLow Blood PressureHerniasFracturesFallsNausea/VomitingPain at NightBlood ClotsStrokeHIV/AIDSType 1 DiabetesType 2 DiabetesHypoglycemiaPins/Metal ImplantsRespiratory ProblemWeight GainWeight LossPacemakerGastrointestinalArthritisDepression/AnxietyNoneOther
Diagnostic Tests - Please check any that apply and list results if known:

MRI:CT Scan:XRAY:Ultrasound/Sono:Urodynamics:Urinalysis:Colonoscopy:Laparoscopy:CystoscopeOther
What are your goals to accomplish with physical therapy?
Patient Name
Signature*
Date

MonthDayYear
Date
Consent and Acknowledgement
Consent:

I hereby consent to physical therapy and incidental medical services to be provided by Lisenby Physical Therapy. I understand that if I am being seen for a pelvic or breast condition it may be necessary to perform an internal pelvic floor exam or breast exam as part of my initial evaluation and periodically throughout treatment. I understand that I have the option to have a second person, or chaperone, present in the exam room for my evaluation and treatment sessions. I understand that a chaperone can be available upon my request or that I can bring a chaperone of my choice with me to my visits. I also understand I may decline having a second person or chaperone in the room.

Liability:

I understand and agree that Lisenby Physical Therapy will not be responsible for loss or damage to my personal properties or valuables while I am on the premises of Lisenby Physical Therapy.

Acknowledgement:

I acknowledge that I have been provided the opportunity to receive the privacy policy statement of Lisenby Physical Therapy. I understand I can request a paper copy of the notice at any time.

Release of Information:

I allow Lisenby Physical Therapy to provide information to any third party payors or those hired by the third party payers which may be partially or wholly responsible for payment of my physical therapy bill. I allow Lisenby Physical Therapy to release information to Tebra on my behalf for billing of the said third party payers. I also allow Lisenby Physical Therapy to release my information to the provider or office of provider from which I was referred or provided to Lisenby Physical Therapy.
Lisenby Physical Therapy may release information to (please select where acceptable) Patient by Voicemail or Text regarding:

SchedulingBillingPhysical therapy/health information
Lisenby Physical Therapy may release information to (please select where acceptable) Family members by Voicemail or Text regarding:

SchedulingBillingPhysical therapy/health information
Please feel free to list any specific instructions you would like Lisenby Physical Therapy to follow
Emergency Contact Name*
Emergency Contact Phone Number*
Patient Name (Print)
Patient Signature (or Guardian if Minor)*
Date

MonthDayYear
Date
Financial Policy
Thank you for choosing Lisenby Physical Therapy for your physical therapy needs. Please review the following policy regarding financial responsibilities for your care.

Patient Responsibility:

All co-pays, co-insurance, deductibles, and self-pay balances are due at the time of service.
We require a valid credit card to be retained on file for payment. If you do not wish your credit card to be charged at the time of service, please provide an alternate form of payment at each time of service and make arrangements with us for any outstanding balances that may remain following your discharge from care. A $35 fee will be charged for any returned check unpaid by your financial institution. Please be advised any billing related statements, receipts, or outstanding balances will come via email from Tebra Patient Portal, our secure billing software platform. You may pay any outstanding balance through this secure portal as well. If you have not provided us an email, you will receive all billing related material via mail.
Insurance and personal information provided must be accurate and up to date. Failure to notify us of changes to your insurance may result in delays in processing or denials to your claims for which you will be responsible.
Your progress in therapy is directly tied to your adherence to your prescribed treatment plan. It is our top priority to help you attain your goals. To do this, we book a one-on-one session for you with your therapist for every visit. If you do not show for your appointment, we do charge a $100 no show fee as we are then unable to fill your reserved spot with another patient. If you cancel with less than 24 hours notice, we charge a $50 fee. If you need to cancel or re-schedule, please give us greater than 24 hours notice to eliminate incurring any fees.
Past due accounts will be charged a delinquency fee of 1.5% per month if left unpaid after 60 days beyond the initial billing period. Lisenby Physical Therapy reserves the right to submit all necessary information to a collections agency for failure to pay 90 days beyond the initial billing period. You will be responsible for the balance defaulted and all charges including collection agency fees, which are typically 33% to 50% of the unpaid balance, recorder's fees for depositions and at trial expenses we incur in enforcing our rights under this policy.

Bill insurance:
We participate in several insurance plans. If you have provided your insurance information, as a courtesy we have verified your physical therapy benefits to the best of our ability at the time requested. This is, however, not a guarantee of coverage. It is your responsibility to be aware of your individual benefits, including all deductible amounts, copays, and coinsurances and whether you are in-network or out-of-network. You will be responsible for all balances due not covered by your insurance company. Please be aware that some, and perhaps all, of the services provided may not be completely covered by your insurance company. Please notify us immediately of any changes to your insurance policy.

Self pay:
If you do not carry health insurance, or wish to not bill your insurance, our self-pay rate for a physical therapy evaluation is $150 and for physical therapy treatments are $125 per visit.
Please select one of the following:*

Bill insuranceSelf Pay
Patient Name (Print)*
I have read the Financial Policy and I agree to the terms and conditions outlined within this policy. Furthermore, I agree to assign all health insurance benefits directly to Lisenby Physical Therapy. I acknowledge this policy will remain in effect until revoked by me in writing.*
Date

MonthDayYear
Date
Credit Card Authorization Form
This form authorizes Lisenby Physical Therapy to charge your deductible, co-pay, coinsurance balances, and/or no-show or cancellation fees to your credit card. The undersigned agrees and authorizes Lisenby Physical Therapy to save the credit card information indicated below on file. A receipt for each payment will be provided to you and the charge will appear on your credit card statement.

Deductible and Coinsurance Balances: After we have received your explanation of benefits back from your insurance company, your credit card will be charged for the patient balance of any deductible and/or co-insurance owed by you the first week of each month or at the time of your next visit, whichever comes first. After you are discharged from care any remaining balances will be charged the first week of each of the following months until all visits are paid for.

Copay / Self Pay: Your credit card will be charged at the time of service for each session.

No-Show and Cancellation Fees: Your credit card will be charged at the time of any missed appointments that are not cancelled with 24 hours advance notice per policy.

It is our policy to require a card be retained on file. If you do not wish us to charge your card on the day of your appointment, you can provide an alternative form of payment such as check, etc. You will fill this form out in office at your first appointment. Please be prepared with the necessary card information. Thank you!
Please sign below indicating you have read the above policies. *
Should be Empty:

Pelvic Male Medical History Form

Consent and Acknowledgement

Financial Policy

Credit Card Authorization Form