Longevity - Intake Paperwork

1
Full Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Year
Month
Day
3
Social Security Number
4
Phone Number* This field is required.
5
Email
example@example.com
6
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Emergency Contact* This field is required.
Name
Phone number
Relationship
8
Referring Physician* This field is required.
9
Date of last MD visit* This field is required.
Date
Year
Month
Day
10
Date of next MD visit
Date
Year
Month
Day
11
Insurance Type* This field is required.
Medicare
Commercial
Private Pay
Car Insurance
Work Comp
12
Are you looking for service in the Office or in your home?(Medicare covers outpatient therapy services at home)
OfficeHome
13
Are you interested in learning about our advanced home exercise program?Covered by Medicare
YESNO
14
Check the conditions that apply to you:* This field is required.
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Hepatitis
Osteoporosis
Pace Maker
History of Heart disease
None Apply
Other
15
Which is your problem area?* This field is required.Chose the best option (We will go into more detail in Evaluation)
Back
Neck
Shoulder
Hip
Knee
Foot/ Ankle
Arm/ Hand
Vertigo
Balance
Strength
Leg
Other
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Specify* This field is required.
Upper Body
Lower Body
Both
17
Did you have surgery for this issue prior to receiving therapy?* This field is required.Please chose the beast answer
Yes
No
18
Pain Score: Over the past 24 hours, how bad has your pain been?* This field is required.
Please Select
Please Select
0
1
2
3
4
5
6
7
8
9
10
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Part A: Daily Activities* This field is required.Open a tight or new jar
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
Unable to do
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2. Do heavy household chores (e.g. wash walls, wash floor)* This field is required.
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
Unable to do
21
3. Carry a shopping bag or briefcase* This field is required.
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
Unable to do
22
4. Wash your back* This field is required.
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
Unable to do
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5. Use a knife to cut food* This field is required.
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
Unable to do
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6. Recreational activities in which you take some force or impact through the shoulder, hand or arm. (golf, hammering, tennis etc.)* This field is required.
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
Unable to do
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7. During the past week, to what extent has your arm, shoulder or hand problem interfered with your normal social activities with family, friends, neighbors, or groups? (mark one)* This field is required.
Not at all
Slightly
Moderately
Quite a bit
Extremely
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8. During the past week, were you limited in your work or other regular daily activities as a result of your arm, shoulder or hand problem? (mark one)* This field is required.
Not limited at all
Slightly limited
Moderately limited
Very limited
Unable
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Part B: Symptoms* This field is required.9. Arm, shoulder, or hand pain
None
Mild
Moderate
Severe
Extreme
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10. Tingling (pins and needles) in your arm, shoulder or hand* This field is required.
None
Mild
Moderate
Severe
Extreme
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11. During the past week, how much difficulty have you had sleeping because of pain in your arm, shoulder, or hand? (mark one answer)* This field is required.
None
Mild difficulty
Moderate difficulty
Severe difficulty
So much difficulty that I can't sleep
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We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your lower limb problem for which you are currently seeking attention. Please provide an answer for each activity. Today, do you or would you have any difficulty at all with:* This field is required.1. Any of your usual work, housework, or school activities
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little difficulty
No Difficulty
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This questionnaire has been designed to give us information as to how your back or leg pain is affecting your ability to manage in everyday life. Please answer by selecting the statement which best applies to you. We realize you may consider that two or more statements in any one section apply but please just indicate the statement which most clearly describes your problem.* This field is required.1. Pain Intensity
I can tolerate the pain I have without using pain medication.
The pain is bad, but I can manage without having to take pain medication.
Pain medication provides me with complete relief from pain.
Pain medication provides me with moderate relief from pain.
Pain medication provides me with little relief from pain.
Pain medication has no effect on my pain.
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Pain Intensity* This field is required.
I have no pain at the moment
The pain is very mild at the moment
The pain is mild at the moment
The pain is fairly sever at the moment
The pain is Very sever at the moment
The pain is the worst imaginable at the moment
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2. Personal care ( washing, dressing etc.)* This field is required.
I can take care of myself normally without causing increased pain.
I can take care of myself normally, but it increases my pain.
It is painful to take care myself, and I am slow and careful.
I need some help, but I am able to manage most of my personal care.
I need help every day in most aspects of my care.
I do not get dressed, wash with difficulty, and stay in bed.
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3. Lifting* This field is required.
I can lift heavy weights without increased pain.
I can lift heavy weights, but it causes increased pain.
Pain prevents me from lifting heavy weights off the floor, but I can manage if the weights are conveniently positioned (e.g. on a table).
Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned.
I can lift only very light weights.
I cannot lift or carry anything at all.
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4. Reading* This field is required.
I can read as much as I want to with no pain in my neck.
I can read as much as I want to with slight pain in my neck.
I can read as much as I want with moderate pain in my neck.
I can’t read as much as I want because of moderate pain in my neck.
I can hardly read at all because of severe pain in my neck.
I cannot read at all.
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5. Headaches* This field is required.
I have no headaches at all.
I have slight headaches which come infrequently.
I have moderate headaches which come infrequently.
I have moderate headaches which come frequently.
I have severe headaches which come frequently.
I have headaches almost all the time.
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6. Concentration* This field is required.
I can concentrate fully when I want to with no difficulty.
I can concentrate fully when I want to with slight difficulty.
I have a fair degree of difficulty in concentrating when I want to.
I have a lot of difficulty in concentrating when I want to.
I have a great deal of difficulty in concentrating when I want to.
I cannot concentrate at all.
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7. Work* This field is required.
I can do as much as I want to.
I can only do my usual work, but no more.
I can do most of my usual work, but no more.
I cannot do my usual work.
I can hardly do any work at all.
I can’t do any work at all.
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8. Driving* This field is required.
I can drive my car without any neck pain.
I can drive my car as long as I want with slight pain in my neck.
I can drive my car as long as I want with moderate pain in my neck.
I can’t drive my car as long as I want because of moderate pain in my neck.
I can hardly drive at all because of severe pain in my neck.
I can’t drive my car at all.
40
9. Sleeping* This field is required.
I have no trouble sleeping.
My sleep is slightly disturbed (less than 1 hour sleep loss).
My sleep is mildly disturbed (1-2 hour sleep loss).
My sleep is moderately disturbed (2-3 hours sleep loss).
My sleep is greatly disturbed (3-5 hours sleep loss).
My sleep is completely disturbed (5-7 hours sleep loss).
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10. Recreation* This field is required.
I am able to engage in all my recreational activities with no neck pain at all.
I am able to engage in all my recreational activities with some pain in my neck.
I am able to engage in most but not all of my usual recreational activities because of pain in my neck.
I am able to engage in a few of my usual recreational activities because of pain in my neck.
I can hardly do any recreational activities because of pain in my neck.
I can’t do any recreational activities at all.
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4. Walking* This field is required.
Pain does not prevent me walking any distance.
Pain prevents me from walking more than 1 mile.
Pain prevents me from walking more than ½ mile.
Pain prevents me from walking more than ¼ mile.
I can only walk with crutches or a cane.
I am in bed most of the time and have to crawl to the toilet.
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5. Sitting* This field is required.
I can sit in any chair as long as I like.
I can only sit in my favorite chair as long as I like.
Pain prevents me sitting more than one hour.
Pain prevents me from sitting more than 30 minutes.
Pain prevents me from sitting more than 10 minutes.
Pain prevents me from sitting at all.
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6. Standing* This field is required.
I can stand as long as I want without increased pain.
I can stand as long as I want, but it increases my pain.
Pain prevents me from standing for more than 1 hour.
Pain prevents me from standing for more than 30 minutes.
Pain prevents me from standing for more than 10 minutes.
Pain prevents me from standing at all.
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7. Sleeping* This field is required.
Pain does not prevent me from sleeping well.
I can sleep well only by using pain medication.
Even when I take pain medication, I sleep less than 6 hours.
Even when I take pain medication, I sleep less than 4 hours.
Even when I take pain medication, I sleep less than 2 hours.
Pain prevents me from sleeping at all.
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8. Social Life* This field is required.
My social life is normal and does not increase my pain.
My social life is normal, but it increases my level of pain.
Pain prevents me from participating in more energetic activities (e.g. sports, dancing, etc.).
Pain prevents me from going out very often.
Pain has restricted my social life to my home.
I have hardly any social life because of my pain.
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9. Traveling* This field is required.
I can travel anywhere without increased pain.
I can travel anywhere, but it increases my pain.
My pain restricts my travel over 2 hours.
My pain restricts my travel over 1 hour.
My pain restricts me to short necessary journeys under 30 minutes.
My pain prevents me from traveling except to the physician/therapist or hospital.
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10. Employment/Homemaking* This field is required.
My normal homemaking/job activities do not cause pain.
My normal homemaking/job activities increase my pain, but I can still perform all that is required of me.
I can perform most of my homemaking/job duties, but pain prevents me from performing more physically stressful activities (e.g. lifting, vacuuming, etc.).
Pain prevents me from doing anything but light duties.
Pain prevents me from doing even light duties.
Pain prevents me from performing any job or homemaking chores.
49
2. Your usual hobbies, recreational or sporting activities* This field is required.
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little difficulty
No Difficulty
50
3. Getting into or out of the bath* This field is required.
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little difficulty
No Difficulty
51
4. Walking between rooms* This field is required.
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little difficulty
No Difficulty
52
5. Putting on your shoes or socks* This field is required.
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little difficulty
No Difficulty
53
6. Squatting* This field is required.
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little difficulty
No Difficulty
54
7. Lifting an object, like a bag of groceries from the floor* This field is required.
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little difficulty
No Difficulty
55
8. Performing light activities around your home* This field is required.
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little difficulty
No Difficulty
56
9. Performing heavy activities around your home* This field is required.
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little difficulty
No Difficulty
57
10. Getting into or out of a car* This field is required.
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little difficulty
No Difficulty
58
11. Walking 2 blocks* This field is required.
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little difficulty
No Difficulty
59
12. Walking a mile* This field is required.
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little difficulty
No Difficulty
60
13. Going up or down 10 stairs (about 1 flight of stairs)* This field is required.
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little difficulty
No Difficulty
61
14. Standing for 1 hour* This field is required.
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little difficulty
No Difficulty
62
15. Sitting for 1 hour* This field is required.
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little difficulty
No Difficulty
63
16. Running on even ground* This field is required.
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little difficulty
No Difficulty
64
17. Running on Uneven ground* This field is required.
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little difficulty
No Difficulty
65
18. Making sharp turns while running fast* This field is required.
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little difficulty
No Difficulty
66
19. Hopping* This field is required.
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little difficulty
No Difficulty
67
20. Rolling over in bed* This field is required.
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little difficulty
No Difficulty
68
Briefly describe how your symptoms began:* This field is required.
Huge
Large
Normal
Small
Ok
Ok
69
When did symptoms first begin?* This field is required.
Date
Year
Month
Day
70
Height* This field is required.in Inches
71
Weight* This field is required.in pounds
72
Are you currently taking any medication?* This field is required.
Yes
No
73
Would you be interested in learning about supplements that improve recovery and overall well-being?* This field is required.Follow up email will be sent
YESNO
74
Would you like to learn about our cash based full body stretching and recovery zone?
YESNO
75
Please List medicationsor upload a picture on the next slide
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Large
Normal
Small
Ok
Ok
76
Medication list
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What is your Gender?* This field is required.
Male
Female
78
Do you have any medication allergies?* This field is required.
Yes
No
Not Sure
79
Do you use or do you have history of using tobacco?* This field is required.
No
Please Select
Yes
No
80
Are you receiving Home Healthcare? This Includes Nursing, Wound Care, Physical Therapy, Occupational Therapy and Speech Therapy.* This field is required.
NOYES
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⚠️ Important Notice ⚠️

If you accidentally selected “Yes” and you are not currently receiving home health care (nursing, therapy, or aide visits in your home), please click the Previous button and correct your answer.

If you are receiving home health care, please be aware that Medicare will not cover both home health and outpatient physical therapy at the same time.

By continuing, you acknowledge that outpatient therapy may not be covered by Medicare and that you may be personally responsible for the full cost of any services provided during an active home health episode.

Please click Next to continue and review the Advance Beneficiary Notice (ABN) before proceeding.
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Advance Beneficiary Notice of Non-Coverage (ABN) - Home Health Overlap Medicare normally covers outpatient physical therapy services. However, Medicare will not pay for outpatient therapy provided while you are receiving care under a Home Health Agency. If you are currently under a Home Health plan of care (or start one while in an active episode with Longevity Rehab Center) and we provide outpatient therapy during that time, Medicare will deny payment, and you may be responsible for the full cost. Estimated cost per session: $125* This field is required.By Signing bellow you agree to the following statement : I want to receive the service and agree to be personally responsible if Medicare does not pay.
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I hereby certify that the information provided above is true and accurate to the best of my knowledge.* This field is required.
84
I the undersigned, hereby consent to such treatment by the authorized personnel of Longevity Rehab Center, Inc., as may be dictated by prudent medical practice of my illness, injury, or condition. This consent is intended as a waiver of liability for such treatment excepting acts of negligence. The undersigned certifies that the information given by me in applying for payment under the Title XVII of the Social Security act is correct. I, the undersigned, authorize Longevity Rehab Center, Inc. to release information regarding my health care to the Social Security Administration, its intermediaries, or any other insurance carrier, or my attorney needed for this or a related claim. I authorize payment from Medicare, Commercial insurance plans and Workers Compensation to be made directly to Longevity Rehab Center, Inc., on my behalf. I hereby instruct and direct that: my Supplemental/Commercial Insurance Company pay by check made out and mailed to: Longevity Rehab Center 1515 Indian River Boulevard Vero Beach, FL 32960 the professional or medical expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This pay is not exceeding my indebtedness to the above mentioned assignee and I have agreed to pay any balance of the said professional service charges over and above this insurance payment. A PHOTOCOPY OF THIS ASSIGNMENT SHALL BE CONSIDERED AS EFFECTIVE AND VALID AS THE ORIGINAL.* This field is required.
85
I acknowledge that I have received a copy of Longevity Rehab Center Inc., notice of privacy practices with the effective date of 04/01. (See Link below)* This field is required.https://www.longevityrehab.com/privacy.html
Date
Month
Day
Year
86
I release Longevity Rehab Center to contact my family or responsible party in case of a medical emergency. I also give them permission to send me to Indian River Medical Center Emergency Room for treatment, If other hospital is preferred, please indicate below.* This field is required.If Other, Please type below
Accept
Other
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We ask that you please keep your scheduled appointment times. If you need to cancel your appointment, we ask that you give us twenty-four (24) hours advance notice. We understand emergencies arise without notice. We also want you to understand the importance of keeping your scheduled therapy visits in order to properly reach your rehab goals. However, if it becomes a habit that you are cancelling your appointments without twenty-four (24) hour notice or not showing for appointments, a $20.00 charge will be billed to the patient. TWO NO SHOW VISITS WITH NO COMMUNICATION WILL RESULT IN TERMINATION OF CARE.* This field is required.
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Drivers License or other Government ID
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Insurance Front and Back
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