Form
Name
*
First Name
Last Name
Preferred Name
*
What would you like us to call you
Date of Birth
*
-
Month
-
Day
Year
Date
If Under 18, Guardian Name
If Under 18, Guardian Date of Birth
If Under 18, Guardian Contact Number
Email
*
example@example.com
Mailing Address
*
Street Address or PO Box
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Primary Insurance Carrier
*
Insurance ID #
Secondary Insurance Carrier
Insurance ID #
Occupation and Employer
*
Gender
*
If Female, Are you Pregnant
Height
*
Weight
*
Handedness
*
Please Select
Right
Left
Primary Care Physician/Clinic
*
Referring Doctor
Reason for Physical Therapy
*
For Example: Back Pain, Muscle Weakness, etc.
Date of Onset
Date of Surgery (If applicable)
Special Tests Done
For Example: X-Rays, MRI, etc.
Check which apply:
*
Work-Related
Motor Vehicle Accident
Injury related to lifting or falling
Recreational or athletic injury
Recurrence of previous injury
Post-Surgery Rehabilitation
Cause Unknown
Other
What treatments have you tried?
*
Medications
Physical Therapy
Massage
Chiropractic
Steroid Injections
Surgery
Other
None
List Medications you are taking
*
Allergies
*
Sensitivity or Allergy to Latex
*
Yes
No
History of:
*
High Blood Pressure
Stroke
Emphysema
Diabetes
Heart Disease
Cancer
Seizure Disorder
Asthma
Fibromyalgia
Lupus
Other
Current:
*
Chest Pain
Fatigue
Shortness of Breath
Balance Problems
Change in bathroom habits
Significant weight loss
Significant weight gain
Swelling
Headaches
Diziness
Fainting
Sleeping Problems
None
Other
Please describe the specific issue you are coming in for and any body parts that are affected.
*
Draw on the image to indicate where your pain is:
*
Check all that apply to categorize your pain:
*
Achy/Dull
Sharp
Tingling
Worse in the AM
Worse in the PM
Intermittent
Continuous
N/A
Rate your pain right now
*
0 if non-existent, 10 unbearable
Rate your pain when it is at its best
*
0 if non-existent, 10 unbearable
Rate your pain when it is at its worst
*
0 if non-existent, 10 unbearable
What makes your pain better
*
Sitting
Standing
Sleeping
Walking
Bending forward
Bending backward
Laying flat
Taking medication
Nothing
What makes your pain worse
*
Sitting
Standing
Sleeping
Walking
Bending forward
Bending backward
Laying flat
Walking up or downstairs
Nothing
Do you smoke?
Yes
No
Do you drink alcohol?
Yes
No
Do you regularly exercise?
Yes
No
Are you feeling down, depressed, or hopeless?
Yes
No
Do you live alone?
Yes
No
Do you have stairs at home?
Yes
No
What is your goal for therapy at this time?
*
For example: relieve pain, return to previous level of function, gain strength
Are there any important activities you are unable to do due to your pain/symptoms?
*
For example: Walking up stairs, reaching overhead, rising from a seated position
If you are able to do so, please upload a picture of your ID, insurance card, and any other documents (such as MRI results, referral, etc.) we may need.
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If there is anyone you authorize to pick up your private health documents on your behalf, please list their name below.
*
I, the undersigned, do hereby agree and give my consent for Custom Fitness, LLC to furnish medical care and treatment t that is considered necessary and proper in diagnosis or treatment.
*
I authorize Custom Fitness, LLC to release to the insurance carrier any information needed for the payment of any claim. I authorize payment to Custom Fitness, LLC from my insurance carrier or third party payer. I agree to pay any applicable cash payments, co-payments, coinsurance and/or deductibles at the time of service and as agreed between Custom Fitness, LLC and me. I understand that my insurance benefits may not cover all charges and that I am responsible for those charges not covered by my health insurance or third party payer. I understand and agree that if I fail to make any of the payments for which I am responsible in a timely manner, I will be responsible for all costs of collecting monies owed, including court costs, collection agency fees, and attorney fees. The above may not apply for those patients that are considered Worker’s Compensation. However, be advised if you claim Worker’s Compensation benefits and are subsequently denied such benefits, you may be held responsible for the total amount of charges for services rendered to you. By my signature, I authorize Custom Fitness, LLC, to release all information necessary, including medical records, to secure payment.
*
To receive the most benefit from rehabilitation, it is important that you follow the treatment plan prescribed by your physician and therapist and attend all sessions on a regular basis. We ask that you give us at least prior day notice if you must cancel your appointment. Cancellations made on the same day and/or NO-SHOW appointments may be subject to a charge which will be billed directly to you. Insurance companies will not cover missed appointment charges. If you miss 2 consecutive appointments without notice, all subsequent appointments will be canceled and your failure to comply with your treatment plan may be reported to your primary care physician and insurance company.
*
I have had full opportunity to read the Custom Fitness, LLC Notice of Privacy Practices. I understand that by signing this consent, I am giving my consent to Custom Fitness, LLC to use and disclose my protected health information to carry out treatment, payment activities and health care operations. I understand the terms of this notice may change with time
*
I authorize Custom Fitness to contact me as necessary.
*
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