Patient Intake

First Name
MI
Last Name
Address

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Male
Female
Email Address
example@example.com
HomePhone
Cell Phone
Work Phone
Emergency Contact Information:
Name
Phone
Address

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Employer Name
Employer Address

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Days Per Week
Hours per Day
Full time
Part time
How did you hear about Dynamic Edge Physiotherapy?
Notice of Privacy Practices

I hereby acknowledge that I have been made aware of Dynamic Edge Physiotherapy's Privacy Practices (copy available at front desk or on the Dynamic Edge website I may request a copy of any amended Notice of Privacy Practices at any time. Authorization to Release/Obtain Information I hereby authorize the release of any and all information to my insurance company or other appropriate party, as required, pertaining to treatment rendered to me by Dynamic Edge Physio Therapy. Further, I authorize Dynamic Edge Physiotherapy to obtain needed information from my physician, employer or insurance. This correspondence can be obtained via mailings, phone, fax or email. Payment/Insurance Eligibility Payment is due at the time of treatment. Verification of benefits is NOT a guarantee of payment. Payment is determined at the time a claim is received. We provide you with the information as it is outlined by your insurance company. It is your responsibility to contact your insurance company to fully understand your benefits. All unpaid & undisputed balances over 30 days will be charged to the credit card provided at registration. We reserve the right to charge interest on any balance that exceeds 30 days. In the event my account is referred to a third party for collection purposes, I will be responsible for all charges up to the statutory limit. Returned Check Fee: A $35 service fee will be charged for any returned checks.

Appointments and Cancellations

We advise you to schedule your appointments in advance. Maintaining a consistent schedule ensures your best outcome for a speedy recovery.

We expect you to keep all of your appointments with Dynamic Edge Physiotherapy and require 24 hours notice if you are unable to keep an appointment. Failure to cancel appointments within 24-hours will result in a $75.00 charge. No Shows will result in a $100 charge. These charges will not be reimbursed by any insurance company.

Cell Phone Use

For your benefit, as well as others around you, please refrain from using your cell phone or other electronic devices during your physical therapy session.
Patient or Guardian's Signature

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Patient Name
Initial Evaluation Date

MonthDayYear
Date
Height
Weight
Do you have a prescription/referral from your doctor?

YesNo
Referring Provider
With whom do you live? (In order to better plan your care) AloneChild/Children Spouse/Significant Other Other Relative(s)Other Group setting

AloneSpouse/Significant OtherRelativesGroup Setting
History of Present Conditions:
Current Complaints
Body Part/Region
When did your symptoms start (date)?
If you are coming in due to an injury, how did you injure yourself?
Special orders from your Physician
Have you seen anyone else for this problem? Please list
If you are coming in after surgery, please explain
Please describe your pain: (i.e.: Burning/stabbing/ache)
Where is your pain located?
When is the pain at its worst?

MorningNightWith ActivityAt Rest
Rate your Pain Level Now (0 No Pain - 10 Worst)
Rate your Pain Level At it's Best (0 No Pain - 10 Worst)
Rate your Pain Level at it's Worst (0 No Pain - 10 Worst)
How are your symptoms?

Getting BetterWorseStaying the Same
What makes your symptoms worse?
What makes your symptoms better?
What activities do you have difficulty doing?
What previous activities do you want to resume?
PAST MEDICAL HISTORY:
Please check all that apply.

If none of the below apply, please check here.CancerLung DiseaseUnusual Join Pain/SwellingAllergiesEmphasema/BrochitisHepatitisKidney DiseaseHeart Problems/DiseaseOsteoporosisHistory of FracturesHigh Blood PressureMultiple SclerosisOther Arthritic ConditionsImpaired HearingDepressionStrokePregnantShortness of BreathThyroid ConditionImpaired VisionCirculation ProblemsEpilepsyHeadacheAsthmaRheumatoid ArthritisDiabetes
Do you use any of the following?

CaneWalker, Rolling Walker or RollatorManual WheelchairMotorized Wheelchair
General Health Status

SmokerObeseAlcohol DependantDrug Dependant
Patient's Self Rated Health Status (Poor, Good, Very Good, Excellent)
List All Surgical Procedures/Dates Here
List Diagnostic Tests/Dates for this problem (xray, MRI, EMG, etc)
List current medications, dosage, frequency and purpose (including over the counter):
INFORMED CONSENT FOR PHYSICAL THERAPY SERVICES

Physical therapy is a patient care service that is provided in order to manage a wide variety of conditions. Services are provided to individuals of all ages regardless of gender, color, ethnicity, creed, national origin, or disability. The purpose of physical therapy is to treat disease, injury and disability by examination, evaluation, diagnosis, prognosis and intervention by use of rehabilitative procedures, mobilization, massage, exercises, and physical agents to aid the patient in achieving their maximum potential within their capabilities and to accelerate convalescence and reduce the length of functional recovery. All procedures will be thoroughly explained to you before you are asked to perform them. Response to physical therapy intervention varies from person to person; hence, it is not possible to accurately predict your response to a specific modality, procedure, or exercise protocol. Dynamic Edge Physiotherapy does not guarantee what your reaction will be to a specific treatment, nor does it guarantee that the treatment will help resolve the condition that you are seeking treatment for. Furthermore, there is a possibility that the physical therapy treatment may result in aggravation of existing symptoms and may cause pain or injury. It is your right to decline any part of your treatment at any time before or during treatment, should you feel any discomfort or pain or haveother unresolved concerns. It is your right to ask your physical therapist about the treatment they have planned based on your individual history, physical therapy diagnosis, symptoms, and examination results. Consequently, it is your right to discuss the potential risks and benefits involved in your treatment. I have read this consent form and understand the risks involved in physical therapy and agree to fully cooperate, participate in all physical therapy procedures, and comply with the established plan of care. I authorize the release of my medical information to appropriate third parties.
Patient Name
Signature

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Date

MonthDayYear
Date
FUNCTIONAL DRY NEEDLING® CONSENT AND REQUEST FOR PROCEDURE

Functional Dry Needling® (FDN) involves inserting a tiny monofilament needle in a muscle or muscles in order to release shortened bands of muscles and decrease trigger point activity. This can help resolve pain and muscle tension, and will promote healing. This is not traditional Chinese Acupuncture, but is instead a medical treatment that relies on a medical diagnosis to be effective. Your physical therapist trained by KinetaCore® has met requirements for competency in Functional Dry Needling and is considered a certified Functional Dry Needling Practitioner. All training was in accordance with requirements dictated by this facility and by the U.S. state of this practitioner's licensure. FDN is a valuable and effective treatment for musculoskeletal pain. Like any treatment, there are possible complications. While complications are rare in occurrence, they are real and must be considered prior to giving consent for treatment. Risks: The most serious risk with FDN is accidental puncture of a lung (pneumothorax If this were to occur, it may likely require a chest x-ray and no further treatment. The symptoms of shortness of breath may last for several days to weeks. A more severe puncture can require hospitalization and re-inflation of the lung. This is a rare complication, and in skilled hands it should not be a major concern. Other risks include injury to a blood vessel causing a bruise, infection, and/or nerve injury. Bruising is a common occurrence and should not be a concern. Patient's Consent: I understand that no guarantee or assurance has been made as to the results of this procedure and that it may not cure my condition. My therapist has also discussed with me the probability of success of this procedure, as well as the probability of serious side effects. Multiple treatment sessions may be required/needed, thus this consent will cover this treatment as well as consecutive treatments by this facility. I have read and fully understand this consent form and understand that I should not sign this form until all items, including my questions, have been explained or answered to my satisfaction. With my signature, I hereby consent to the performance of this procedure and to any measures necessary to correct complications which may result. I authorize Dynamic Edge Physiotherapy to perform Functional Dry Needling® as part of my physical therapy treatment.

DO NOT SIGN UNLESS YOU HAVE READ & THOROUGHLY UNDERSTAND THIS INFORMATION.

You have the right to withdraw consent for this procedure at any time before it is performed.
The following questions must be answered for Dry Needling:

Check here if you are pregnantCheck here if you are taking blood thinnersCheck here if you are immune compromised
Patient or Authorized Representative Signature

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Date

MonthDayYear
Date
Relationship to Patient (if other than patient)
Should be Empty:

PAST MEDICAL HISTORY: