BARWIS Physical Therapy Questionnaire

This form must be filled out and submitted in order for you to be considered for a scheduled appointment in our Barwis Methods Injury Recovery program.

GENERAL

Full Name*

First NameLast Name

Gender

Birth Date*

MonthDayYear

Cell Phone Number*

Area CodePhone Number

Home Phone Number*

Area CodePhone Number

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Insurance Company*

Name of Insurance Carrier

Policy Number*

Emergency Contact*

First NameLast Name

Phone Number*

Area CodePhone Number

How did you hear about us?*

If Other please specify:

MEDICAL

Referring Doctor

First NameLast Name

Phone Number

Area CodePhone Number

Date of last doctors visit

MonthDayYear

Primary care doctor *

First NameLast Name

Phone Number*

Area CodePhone Number

EMPLOYMENT

Employment status

Employed-Full timeEmployed- Part timeStudentRetired

Professional athlete

YesNo

ACCIDENT RELATED (IF APPLICABLE)

Date of first symptom*

MonthDayYear

Employment related?*

YesNo

Lawsuit involved?*

YesNo

CURRENT INJURY

Chief complaint/concern*

Date of injury *

MonthDayYear

Date of surgery (if applicable)

MonthDayYear

Briefly describe how you injured *

Have you received therapy for this injury *

YesNo

Please indicate area(s) where symptoms occur:

Circle the area where symptoms occur:

Please rate your current degree of pain (0= no pain, 10= severe pain)*

Please rate pain at its worst, (0= no pain, 10= severe pain)*

During which activity(ies) is your pain at its worst?*

What makes your pain better?*

What are your goals to be acheived by the end of physical therapy *

Please list all current medications (Rx, Over the counter, Home remedy):*

Please indicate what studies were performed:

If other, please specify:

Results of studies (if known)

Please list any prior surgery(ies):*

REVIEW OF SYSTEMS (Check any/all symptoms you have experienced):

Type:

Any medical history not covered in any of the previous questions?*

I acknowledge that the information above and attached is complete and accurate.

Full Name*

First NameLast Name

On behalf Of*

First NameLast Name

Signature*

Accept*

YesNo

Electronic Signature Agreement. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide Company instructions via Company's website or its affiliates, or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and Company. You also represent that you are authorized to enter into this Agreement.

Signature of Client or Legally Authorized Representative of Client

Date:

MonthDayYear

PHYSICIAN REFERRAL FORM - Please print the physician referral form for your doctor to complete and provide a copy to Barwis Methods upon your first visit.

General/Constitutional:

Respiratory

Endocrine

Ear, Nose, Throat

Allergies

Cancer:

Cardiovascular

Neurological

Hematological/Lymphatic

Musculoskeletal

Gastrointestinal

Opthalmological

Other