Medical History Information

/ Physical Therapy Faculty Practice
California State University, Long Beach
1250 Bellflower Blvd, KIN-105
Long Beach, CA 90840 / Phone: (562) 985-8286
Fax: (562) 985-4266
Email:
Web:

Medical History Information

Patient Name: ______Date of Birth:______Last 4 SSN:______

Age: ______Date of Injury/Surgery / Start of Symptoms: ______

Occupation: ______

Job Duties/Requirements: ______

Is your treatment arising out of an injury that occurred during and in the course and scope of your employment? Y / N

If yes, please note that PT@TheBeach cannot provide treatment for work related injuries that are part of a workers’ compensation claim which occurred at California State University, Long Beach.

Please describe the nature of your injury/symptoms: ______

______

Please shade in the area where you have been experiencing pain in the past week on the body diagram:

/ What increases your pain/discomfort?
______
______
What decreases your pain/discomfort?
______
______
What activities are you having difficulty with as a result of your injury/surgery?
______
______

Please rate your average pain intensity over the past week on the scale below:

NO PAIN ‌├─────────────────────────────────┤WORST PAIN POSSIBLE

Have you had recent diagnostic tests: X-Ray MRI CT Scan EMG NCV Other: ______

List of previous surgeries or medical procedures: ______

______

List current medications, your dosage, frequency, and route of administration: ______

______

General Health/Medical Questionnaire

Patient Name: ______Date of Birth:______Last 4 SSN:______

Do you currently have any of the following symptoms/conditions?

____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
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____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No / Unexplained weight loss/gain
Fevers/Chills/Sweats
Nausea
Headaches
Dizziness/Lightheadedness/Vertigo
Vision Changes
Numbness/Tingling
Chest pain/Palpitations
Shortness of Breath
Difficulty Breathing
Fatigue
Swelling in Feet/Hands
Fainting
Coughing/Wheezing
Blood in Phlegm
Difficulty with Swallowing
Vomiting
Diarrhea
Specific Food Intolerance: ______
Heartburn/Indigestion Change in Appetite
Incontinence
Painful Urination
Blood in Urine
Increased Frequency of Urination
Urinary Urgency
Pregnant / ____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
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____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No
____ Yes ____ No / Abdominal pain
Bowel Pattern Changes
Change in Stool Color
Problems with Coordination
Sudden Weakness
Unexplained Skin Rash
Pain in Other Joints: ______
Arthritis
Allergies:______
Asthma
Balance Problems/Vertigo
History of Falls
Blood Pressure: High/Low
Blood Disorders
History of Cancer
Cancer/Tumor: ______
Unusual Lumps or Growths
Diabetes
Heart/Circulatory Disease
Kidney Disease
Liver Disease
Lung/Pulmonary Disease
Osteoporosis
Seizures
Night Pain
Smoking: ___packs/day
Drinking: ___drinks/day

If you have any symptoms/conditions not mentioned above, please list them here: ______

______

I understand that the above information is an accurate report of my medical history to the best of my knowledge. This information will be utilized by my physical therapist to develop the best possible treatment and exercise program for me.

Patient Signature: ______Date: ______PT Signature: ______Date: ______

General Medical/Health Questionnaire

Height: ______(feet, inches) Weight: ______(pounds)

Who do you live with? ______Relationship: ______

Do you have stairs in or around your home? Yes / No (Circle One) If yes, how many? ______

Do you use an assistive device for mobility? Yes / No (Circle One) If yes, what kind? ______

Have you fallen in the last 12 months? Yes / No (Circle One)

General Contact Information

Today’s Date: ______Date of Birth: ____/____/____ Social Security Number: ______-_____-______

First Name: ______Last Name: ______MI: ______

Home Address: ______City: ______Zip Code: ______

Home Phone: ______Cell Phone: ______Work Phone: ______

Email Address: ______Sex: Male/Female Marital Status: Single/Married/Other

Emergency Contact Name: ______Phone Number: ______

How did you hear about us? ______

Primary / Referring Physician Name: ______Specialty: ______

Physician Address: ______City: ______Zip Code: ______

Office Phone Number: ______Fax Number: ______

Workers’ Compensation Patients Only:

Employment Status: Employed/ Unemployed / Other: ______

Employer Name: ______

Work Address: ______City: ______Zip Code: ______

Work Phone Number: ______Title/Position: ______

Patient Signature: ______Date: ______PT Signature: ______Date: ______

Insurance Information

Primary Insurance Company Name: ______

Insurance Company Provider Line Phone Number: ______

Insurance ID Number: ______Group Number: ______

Is your insurance: HMO / PPO (Circle One)

Are you the primary policyholder? Yes / No (Circle One)

If policyholder is other than yourself:

Policyholder’s First Name: ______Last Name: ______

Policyholder’sDate of Birth: ____/____/_____ Policyholder’s Sex: Male/ Female (Circle One)

Relationship: Spouse/Parent/Other: ______(Circle One)

Policyholder’s Address: ______City: ______State: _____ Zip: ______

Secondary Insurance Company Name: ______

Insurance Company Provider Line Phone Number: ______

Insurance ID Number: ______Group Number: ______

Is your insurance: HMO / PPO (Circle One)

Are you the primary policyholder? Yes / No (Circle One)

If policyholder is other than yourself:

Policyholder’s First Name: ______Last Name: ______

Policyholder’sDate of Birth: ____/____/_____ Policyholder’s Sex: Male / Female (Circle One)

Relationship: Spouse / Parent / Other: ______(Circle One)

Policyholder’s Address: ______City: ______State: _____ Zip: ______

Informed Consent

Patient Name: ______Date of Birth:______Last 4 SSN:______

I, the undersigned, hereby give my consent and authorize (Physical Therapist’s Name): ______

to perform the following treatments(s): ______.

Body part (location): ______[ ] Right [ ] Left

Prior to the treatment(s), the physical therapist has explained my diagnosis and has described the nature and purpose of the treatment(s) and given me the opportunity to ask questions. We have discussed:

The risks of the treatment(s), including the risk that the treatment(s) may not accomplish the desired result(s).
The benefits (possible or likely outcomes) of the treatment(s).
Alternative treatments (including the risks and likely effectiveness of each alternative), regardless of cost. We also discussed other available treatment(s) or choosing not to have the treatment(s) and the ramification thereof.

I understand that all treatments may involve risks of unsuccessful results, complications, injury or even death from both known and unforeseeable causes and no guarantee is made as to the results.I authorize the physical therapist to use his/her discretion in the disposal of any human waste resulting from the treatment(s).I have had sufficient opportunity to discuss my condition and the proposed treatment(s) with the physical therapist and my questions have been answered to my satisfaction. I believe that I have adequate information upon which to base my informed consent.

My signature below indicates that:

1)I have read and understand the information provided in this form and any attached forms,

2)The treatment(s) described above has been adequately explained to me by the physical therapist,

3)I have had the chance to ask any questions and received all the information I desire concerning the treatment(s)

4)I authorize and consent to the performance of the treatment(s),

5)I have read and received a copy of the consent and patient education handout for this treatment(s),

6)As a teaching facility, students will be in the clinic participating in patient care under direct supervision of the attending physical therapist.

I understand that this document is written to be as broad and inclusive as legally permitted by the State of California. I agree that if any portion is held invalid or unenforceable, I will continue to be bound by the remaining terms. I have read this document, and I am signing it freely. No other representations concerning the legal effect of this document have been made to me.

______

Patient’s Name (print)Signature of PatientDate

If the Patient is under 18 years of age: I am the parent or legal guardian of the Patient. I understand the legal consequences of signing this document. I allow the Patient to receive treatment at PT@TheBeach. I understand that I am responsible for the obligations and acts of the Patient as described in this document. I agree to be bound by the terms of this document. I have read this document, and I am signing it freely. No other representations concerning the legal effect of this document have been made to me.

______

Patient’s Parent/Legal Guardian Name (print)Signature of Patient’s Parent/Legal GuardianDate

Authorization to Release or Obtain Health Information

Patient Name: ______Date of Birth:______Last 4 SSN:______

Please read the following carefully:

I understand that as part of my health care treatment, PT@TheBeach (the “Practice”) develops and maintains records containing my health information, which include my health history, symptoms, test results, diagnosis, treatment, and claims and payment history.

(a)I hereby authorize a representative of PT@TheBeach to be permitted to review, obtain and release copies of all hospital, medical, vocational, and other related records and to discuss pertinent information with professionals involved in my rehabilitation / physical therapy program.

(b)Furthermore, I hereby give permission to PT@TheBeach to share the information received with any institution that through an insurance program or otherwise is paying all or part of the cost of my rehabilitation / physical therapy program. This authorization permits the release of written reports and discussion of the client’s condition.

This authorization is given freely with the understanding that:

(a)Any and all records, whether written or oral or in electronic format, are confidential and cannot be disclosed without my prior written authorization, except as otherwise provided by law.

(b)A photocopy or fax of this authorization is as valid as this original.

(c)I may revoke this authorization at any time, except where information has already been released. This authorization is valid for a one year period from the date it is signed, or sooner if noted below. The revocation must be in writing. A revocation form is available from the receptionist.

(d)PT@TheBeach, its employees, officers, and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

(e)Treatment, payment, eligibility for benefits may not be conditioned upon obtaining this authorization.

(f)Information used or disclosed pursuant to this authorization may be subjected to re-disclosure by the recipient and is no longer protected by our organization.

______

Patient’s Name (print)Signature of PatientDate

______

Patient’s Parent/Legal Guardian Name (print)Signature of Patient’s Parent/Legal GuardianDate

Cancellation/No-Show Policies

Patient Name: ______Date of Birth:______Last 4 SSN:______

I, ______(patient’s name), will attend my scheduled physical therapy appointments to the best of my ability. However, in the event that I have to cancel, I will adhere to the following cancellation and no-show policies set forth by PT@TheBeach.

Cancellation Policy

All appointments prior to 12:00 PM must be cancelled by 5:00PM the day prior to the scheduled appointment. All appointments after 12:00 PM must be cancelled by 8:00 AM on the day of the scheduled appointment. Failure to cancel your appointment by these deadlines may result in a No-Show fee as stated in the No-Show Policy.

No-Show Policy

If you are unable to cancel your appointment by the deadlines set forth in the Cancellation Policy, you will be given a first-offense grace period. Upon the second offense, you will be assessed a $25 no-show fee. Three (3) no shows during your episode of care may result in your discharge from physical therapy, at the discretion of PT@TheBeach.

______

Patient’s Name (print)Signature of PatientDate

______

Patient’s Parent/Legal Guardian Name (print)Signature of Patient’s Parent/Legal GuardianDate

Direct Physical Therapy Treatment Services Disclosure Statement

Patient Name: ______Date of Birth:______Last 4 SSN:______

You are receiving direct physical therapy treatment services from an individual who is a physical therapist (PT) licensed by the Physical Therapy Board of California.

Under California law, you may continue to receive direct physical therapy treatment services for a period of up to 45 calendar days or 12 visits, whichever occurs first, after which time a physical therapist may continue providing you with physical therapy treatment services only after receiving, from a person holding a physician and surgeon’s certificate issued by the Medical Board of California or by the Osteopathic Medical Board of California, or from a person holding a certificate to practice podiatric medicine from the California Board of Podiatric Medicine and acting within his or her scope of practice, a dated signature on the physical therapist’s plan of care indicating approval of the physical therapist’s plan of care and that an in-person patient examination and evaluation was conducted by the physician and surgeon or podiatrist.

Furthermore, you have the right to obtain physical therapy from a physical therapist of your choice (B&P Code Section 650).

Please sign below to indicate that you have read and understand the above disclosures.

______

Patient’s Name (print)Signature of PatientDate

______

Patient’s Parent/Legal Guardian Name (print)Signature of Patient’s Parent/Legal GuardianDate

Acknowledgment of Notice of Privacy Practices

Patient Name: ______Date of Birth:______Last 4 SSN:______

My signature below indicates that:

1)I have read and understand the information provided to me in the “Notice of Privacy Practices”,

2)The “Notice of Privacy Practices” has been adequately explained to me by the physical therapist,

3)I have had the chance to ask any questions and received all the information I desire concerning the “Notice of Privacy Practices” and

4)I have received a copy of the “Notice of Privacy Practices”.

______

Patient’s Name (print)Signature of PatientDate

If the Patient is under 18 years of age: I am the parent or legal guardian of the Patient. I understand the legal consequences of signing this document. I allow the Patient to receive treatment at PT@TheBeach. I understand that I am responsible for the obligations and acts of the Patient as described in this document. I agree to be bound by the terms of this document. I have read this document, and I am signing it freely. No other representations concerning the legal effect of this document have been made to me.

______

Patient’s Parent/Legal Guardian Name (print)Signature of Patient’s Parent/Legal GuardianDate

Updated 11/30/2018 / Page 1 of 10