Health and Wellness Medical History Form

Full Name

First NameLast Name

What is your date of birth?

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What is your gender?

Contact Number

Email Address

example@example.com

Check the conditions that apply to you or any member of your immediate relatives:

Check the symptoms that you' re currently experiencing:

Are you currently taking any medication?

YesNo

Please list them.

Please list all surgical procedures (Include elective, procedural, and body enhancements)

Do you have any allergies to medications, latex, seasonal?

YesNoNot Sure

Please list them.

Do you use any kind of tobacco or have you ever used them?

What kind of tobacco products? How long have you used/been using them?

Do you use any kind of illegal drugs or have you ever used them?

What kind of drugs? How long have you used/been using them?

How often do you workout?

When you do workout, what type of activity is preferred?

Cardio (Treadmill, elliptical, Stair Climber, Swimming)Fitness Class (Kick boxing, Spin Class, Step aerobics, Yoga)Weight Training (light or heavy weights)Outdoor Walking (park, parking lot, etc.)

I have had the following in the past 6 months to a year

What are your goals for treatment? (Please be detailed)

When would you like to begin treatment?

Date

PLEASE READ!

Charpt.com is a professional website that provides a means to book physical therapy and or wellness services and provide information and resources to the public. The contents of the Comprehensive Health and Rehab, LLC web site, including images, graphics, text, are for informational purposes only. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment unless skilled physical therapy services are rendered by Dr. Gabrielle Jones, PT, DPT, GCS, CLT.

Always seek the advice of your physician, physical therapist, or other qualified healthcare provider with any questions you may have regarding a medical condition or treatment and before undertaking a new health care regimen. If you think you may have a medical emergency, call your doctor or 911 immediately.

Comprehensive Health and Rehab, LLC does not assume any liability for accident or injury resulted from replicating any activities found on this website. Use your best judgement for all activities demonstrated on this website.

Scheduling and Use of Visits

Scheduling will be completed once payment is received.

Refund Policy

All treatments and packages are non-transferable and non-refundable and expire one year from the purchase date. Any unused services in your package will not be refunded.

Notice of rescheduling and cancellation policy

Your health and the health of all of our clients matters to us. To ensure that all of our clients are treated fairly and are able to receive treatment in a timely manner, Comprehensive Health and Rehab, LLC. asks that you provide at least 24-hours notice if you need to change, reschedule or cancel your appointment. If you change or reschedule your appointment without providing us with 24-hours advance notice or fail to keep your appointment (if you are a no-show) you will be charged a fee of $75.

To change or cancel an existing appointment, please contact us at Care@charpt.com or 678-218-8041 or reschedule your appointment.

I acknowledge that I have received and understand Comprehensive Health and Rehab’s cancellation and rescheduling policy and agree that I will be responsible for paying a fee of $75 in the event that I fail to provide Comprehensive Health and Rehab, LLC. with at least 24-hours notice before changing or canceling my appointment.

ARRIVAL
Please arrive 15 minutes prior to your appointment time to allow time to complete paperwork or answer questions about the service you may have. We understand that issues can arise that may cause you to be late for your appointment. However, we ask that you call to inform us if that ever occurs, so we can do our best to accommodate you. Appointment times are reserved for each client, so oftentimes we cannot exceed that reserved time.

PAYMENTS
Because wellness services are elective, we do not bill insurance for these services. All prices are subject to change without notice. We accept cash, Visa®, MasterCard®, Care Credit™, and Comprehensive Health and Rehab Wellness gift cards; we do not accept checks.

GIFT CERTIFICATES
Gift certificates are not redeemable for cash and cannot be replaced if lost or stolen. Gift Certificates are valid for one year from the purchase date.

PATIENT-PROVIDER RELATIONSHIP
We love having you as a patient, but we do reserve the right to refuse service at any time, to anyone, for any reason.

FULL DISCLOSURE
Our #1 goal is for you to be happy with our service and to love the results you achieve. We believe in full disclosure, which means we strive to ensure that you understand the treatments you receive and the risks and benefits associated with each of them. With this in mind, please be assured that our team will only recommend treatments and products that will benefit you specifically and which are medically appropriate for you. And if you have any questions at any time, please ask. We’re here to help!

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