Physical Therapy Medical Form

Physical Therapy Medical Screening Questionnaire

Contact Information

Name:   Age:   Date:

Gender: Male Female   Smoker: Yes No   Pregnant: Yes No

Occupation:

Describe your exercise routine:

Past Medical History

Please select each condition that you have been told you have (or had).

Cancer Diabetes Kidney Disease Liver Disease
Stroke High Blood Pressure Heart Disease Angina/Chest Pain
Ulcers Fibromyalgia Osteoporosis Osteoarthritis
Rheumatoid Arthritis Sexually Transmitted Disease Allergies/Asthma Lung Disease

Other illness or injury, If yes, explain:

Do you take blood thinners? Yes No   Are you allergic to latex Yes No

During the past month, have you been feeling down, depressed, or hopeless? Yes No

During the past month, have you been bothered by little or no interest or pleasure in doing things? Yes No

Past surgical history (list all & date):

Current medications (or provide list separately):

Have you had an x-ray, MRI, or other imaging study?

Current Symptoms

Please select all that apply:

Fever/chills/sweats Poor balance (falls) Unexplained weight loss Numbness or Tingling
Changes in appetite Difficulty swallowing Depression Shortness of breath
Dizziness Headaches Nausea/Vomiting Increased pain at night
Changes in bowel or bladder function

Where are you currently having symptoms?

Body Chart:

Please mark the areas where you feel pain on the chart to the right.

Current Symptoms (continued)

What date (approx.) did your present pain start?

How (gradually, suddenly, injury)?

Your symptoms are currently: Getting better About the same Getting worse

Have you ever had this problem before? Yes No

If so, how was the problem treated?

How long did it take for you to feel better?

How are you able to sleep at night? Well Moderate difficulty Only with medication

What is your personal goal for therapy?

Number of falls in past year: Do you feel unsteady walking/standing? Yes No

Are you worried about falling? Yes No

At the present time, would you say that your health is? Excellent Very good Fair Poor

Pain at present:  Best for the last 48 hours:  Worst for the last 48 hours:

Overall average level of function:

What makes your symptoms better?

What makes your symptoms worse?

Please list the best and worst time of day for your symptoms: Best: Worst:

Aggravating Factors: Identify up to 3 important activities that you are unable to do or are having difficulty with. List them below:

1)

2)

3)

Do you have any barriers to learning? If so list:

Appointment Reminder Consent

Please select ONE method below to contact you with appointment reminders. Choose either email or text:

Email Body Logic Physical Therapy may send email messages to confirm my upcoming appointments.

Email address:

—or—

Text Body Logic Physical Therapy may send cell phone text messages to confirm my upcoming appointments.

I recognize that normal text messaging rates may apply.

Cell phone number:

Please indicate your carrier below:

ALLTel Cricket Wireless Qwest Verizon
AT&T Metrocall Sprint PCS Virgin Mobile
Boost Mobile MetroPCS T Mobile Other
Cingular Nextel US Cellular

Medical Release and Consent

CONSENT: I authorize Body Logic Physical Therapy to release and/or request information to/from insurance companies and all medical providers. I authorize assignment of benefits to Body Logic Physical Therapy. I understand that my diagnosis and treatment plan will be discussed during my appointment and I have the right to question and/or refuse any treatment offered.

Office Policy and Fee Responsibility

Release of information: The undersigned agree that Body Logic Physical Therapy may disclose portions of the patient’s records, to any person or corporation which is or may be liable, for all or any portion, of Body Logic Physical Therapy charges, including but not limited to insurance companies.

Patients are responsible for any portion of their balance that insurance will not cover.

We reserve the right to charge an appointment fee of $50.00 for any scheduled appointment canceled without 24-hour notice or a no show. In the event of 2 (two) consecutive “no show” all future appointments will be canceled and discharge note will be sent to your referring physician.

There will be a $25.00 charge for all returned checks.

Thank you for choosing Body Logic Physical Therapy to assist you in your rehabilitation program. We hope you have a speedy recovery.

I have read the above and agree to comply with the policies set forth.

New Patient Consent to Use and Disclosure of Health Information for Treatment, Payment or Healthcare Operations

I , understand that as part of my health care, Body Logic Physical Therapy originates and maintains paper and/or electronic records describing my health history, symptoms, examination, and test results, diagnoses, treatment, and any plans for future care or treatment.

I understand that this information serves as:

• A basis for planning my care and treatment

• A means of communication among the many health professionals who contribute to my care

• A source of information for applying my diagnosis and surgical information to my bill

• A means by which a third-party payer can verify, that services billed were actually provided and

• A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.

I understand that I have the following rights and privileges:

• The right to review the notice prior to signing this consent.

• The right to object to the use of my health information for directory purposes, and the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or health care options.

I understand that Body Logic Physical Therapy is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by section 164.506 of the code of Federal Regulations.

I further understand that Body Logic Physical Therapy reserves the right to change their notice and practices and prior to implementation, in accordance with section 164.520 of the code of Federal Regulations. Should Body Logic Physical Therapy change their notice, they will send a copy of any revised notice to the address I’ve provided (whether U.S. mail, or if I agree; email).

I understand that as part of this organizations treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses including disclosures via fax.

I fully understand and accept the terms of this consent.

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