PATIENT INFORMATION
Name: ______Patient ID#: ______Sex: [ ]M [ ]F
Address: ______Date of Birth: ______
City: ______State: ______Zip: ______Social Security #: ______
Home Phone: ______Marital Status: [ ] Married [ ] Single
Cell Phone: ______Referring Physician: ______
Email Address: ______Primary Care Physician: ______
______
PATIENT EMPLOYMENT EMERGENCY CONTACTS ( NAME & PHONE)
[ ] Employed [ ] Retired [ ] Not Employed ______
Employer:______
Phone: ______
______
RESPONSIBLE PARTY (Must complete if responsible party is other than the insured or patient.)
[ ] Same as Patient [ ] Same as Insured Relation to Patient:______
Name: ______Employer: ______
Address: ______Phone: ______
City, State, & Zip: ______Date of Birth: ______
Drivers License #______State_____ Social Security#: ______
______
PRIMARY INSURANCE (Must complete in its entirety in order for us to file with your insurance.)
Name of Insured:______Relation to Patient: ______
Name of Insurance Company:______Insured SS#: ______
Insurance Phone #: ______Policy Group #: ______
Insured Employer: ______Insured Date of Birth: ______
______
SECONDARY INSURANCE (if applicable)
Name of Insured:______Relation to Patient: ______
Name of Insurance Company:______Insured SS#: ______
Insurance Phone #: ______Policy Group #: ______
Insured Employer: ______Insured Date of Birth: ______
I understand that this form must be completed in its entirety. I understand that if all of the above information is not completed, a claim may not be able to be filed to my insurance company; therefore, making me fully responsible for any charges incurred.
Patient/Responsibility Party Signature: ______
holisticpt©2014
PATIENT______DOB__________ACCT#______
Assignment of Benefits
I, or authorized representative/legal guardian acting on behalf of the patient hereby authorize payment of insurance benefits under the terms of my policy directly to SPRING FAMILY PHYSICIANS for services rendered.
I am financially responsible and will pay for charges not covered by my insurance plan.
Financial Agreement and Statement of Responsibility
For and in consideration of services rendered or to be rendered the facility, I agree to pay said clinic for all services and charges. I understand that I am responsible for any health insurance deductibles, coinsurance and non-covered charges. I understand payment in full is due at the time services are rendered or payment arrangements are to be made before my appointment. I understand that the amount quoted by the facility as being my responsibility is an estimate only and any patient balance remaining after my insurance has processed my claim will be billed to me and due within 30 days.
I understand that it is my responsibility to inform the office with a minimum of a 24 hour advance notification if I am unable to make any appointment. I understand that I will be charged a fee of $50 for not giving proper notification.
Consent to Medical Treatment by Physician
I, or authorized representative/legal guardian acting on behalf of the patient, do hereby consent to receiving general medical services, which may include routine diagnostic procedures and such medical treatment as the physician, his/her physician assistants or his/her designees consider to be necessary in his/her judgment. I also acknowledge that the practice of medicine is not an exact science and that no guarantees have been made to me as to results of treatment or examination at the facility.
Acknowledge of Review of Privacy Practices
I, the undersigned, have reviewed the Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of the Privacy Practices.
Release of Patient Healthcare Information
I hereby authorize the facility and any subcontractor of, to release or obtain patient healthcare information, including but not limited to reports, prior films/images, in accordance with the policy of the clinic, as is necessary to health care providers to facilitate reimbursement by a health benefit plan or personnel of another health care entity for the purpose of providing current continuum of care including to facilitate reimbursement by a health benefit plan or third party payor, including but not limited to, my insurance carrier, Medicare, Medicaid, and any other payer or agency.
Do you have an advanced directive(living will)? ______YES ______NO
If yes, please bring a copy into our office for our files.
If no, and you would like information on advanced directive, please speak with your physician,
The above authorizations are valid unless you revoke them in writing.
holisticpt©2014
Massage Therapy Waiver and Consent Form
I understand that the massage I receive at Holistic Physical Therapy is provided for the basic purpose of relaxation, stress reduction, and relief of muscular tension. I further understand that the massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, physical therapist, or other qualified medical specialist for any medical for physical ailment that I am aware of.
I understand that massage therapists are not qualified to perform skeletal adjustments, diagnose and /or prescribe, and that nothing said in the course of the session should be construed as such.
Because massage is contraindicated under certain conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I forget to do so.
Patient’s Name: ______
(Please Print)
Patient’s signature : ______Date: ______
17200 State Hwy. 249 Suite 100 Houston, Texas 77064
Phone #: 832-463-4526 Fax# 832-446-3631
What is Trigger Point Therapy?
Trigger Point Therapy is used to retrain muscles back into place for a pain-free active lifestyle. This specific type of therapy involves applying pressure to tender muscle tissue to relieve pain causes dysfunction in other parts of the body. At times, trigger point therapy and massage therapy are performed together to better the chances on finding an irritated point in the body.
What Causes Trigger Points?
Trigger Points are muscles in the body that tighten and can cause tension associated with great pain. The tightness and tension in the muscles are more commonly known as muscle knots and can affect many people. One of the main causes of trigger points is bad posture; however there are other causes which can include:
* Overexertion of muscles
* Injury
* Birthing Trauma
What are the Types of Trigger Points?
Latent and Active Trigger Points are the two types of trigger points.
Latent trigger point is when pain is apparent by the act of pressing against the muscle affected; but this pain is localized, it does not spread through out the body. Latent trigger points can occur in the joints and progress with age.
Active trigger point is when pain is apparent by pressure just like the latent trigger point; however the pain radiates throughout the entire body.
What to Expect During Trigger Point Therapy.
It is imperative to be aware that Trigger Point Therapy will not be complete in just one session. During a normal and routine muscle trigger point therapy session pain and/or bruishing may occur, it is important that swelling and stiffness will not leave in just one session. Each case is different and for best results, it is wise to expect several treatments to relieve and remove the pain. After several therapy sessions, many see improvements in mobility and that less tension is experienced.
Patient Signature: ______Date: ______
It is normal to feel muscle soreness after receiving physical therapy. If the soreness does not resolve after 24 hours, it is recommended that you see the physical therapist the next day for further intervention.
17200 State Hwy. 249 Suite 100 Houston, TX 77064
Phone #: 832-463-4526 Fax# 832-446-3631
Dear Patient,
Thank you for allowing Holistic Physical Therapy to participate in your medical care. Receiving physical therapy treatments (massage & exercise) can cause your body to release lactic acid from your muscles, which can lead to muscle soreness for several days following your treatments.
Suggestions to help you alleviate muscle soreness:
1. Drink plenty of fluids to flush out the lactic acid being released from your sore muscles.
2. Take 3-4 Advil’s or Ibuprofen, 200mg every 8 hours to reduce inflammation/spasm.
3. Use ice or cold packs, 20 minutes at a time the evening of your treatment to reduce pain and swelling.
4. Take a nice long hot shower the next day to relax muscles.
It is normal to fell muscle soreness after receiving physical therapy treatment. If the soreness does not resolve after 24 hours, it is recommended that you see the physical therapist the next day, for further intervention.
Patient’s Name: ______
(Please Print)
Patient’s signature:______Date:______
HOLISTIC PHYSICAL THERAPY LLC
17200 State Hwy 249, Suite 100
HOUSTON, TEXAS 77064
PHONE: 832-463-4526 / FAX: 832-446-3631
Medical History Questionnaire
Name: ______
Date of Birth: ______Sex: M F Phone: ______
Please list the symptoms that brought you here today. Mark them on the body diagram as:
P = pain, N = numbness, T = tingling and W = weakness
Please list the date the symptoms started and if any previous episodes of pain. ______
______
Please list current/previous medical conditions: ______
______
Please list any previous surgeries: ______
______
Please list diagnostic tests recently performed (X-Rays, MRI, CT scan, and PET): ______
______
Please list current medications: ______
______
What makes your symptoms worse? ______
What makes your symptoms better? ______
______
Are symptoms worse in the morning, evening, at night or as the day progresses? ______
How long can you sit and/or stand before symptoms increase? ______
______
Does pain wake you after you fall asleep? (Please circle) YES NO
If YES, how many times? ______
What position(s) do you sleep in? (Please circle more than one if applicable)
BACK STOMACH LEFT SIDE RIGHT SIDE
What type of sleeping surface do you have? (Please circle)
FIRM SOFT SAGGING WATERBED
If employed, what is your occupation? ______
Job Requirements: ______
______
Current work status: (Please circle)
FULL DUTY LIGHT DUTY FULL TIME PART TIME OFF WORK DUE TO INJURY
Do your symptoms limit normal activities of daily living? Please describe. (Cleaning, vacuuming, sweeping, dressing, showering/bathing, yard work etc.)______
______
Please mark on the line below to indicate your pain levels over the last three (3) days with the following: . L= least pain A = average pain C = Current pain W = worst pain
|______|______|______|______|______|______|______|______|______|______|
0 1 2 3 4 5 6 7 8 9 10
(No Pain) (Extreme Pain)
Please list at least two (2) goals that you hope to accomplish by participating in physical therapy: ______
When is your next follow – up appointment with your physician? ______
Thank you for assisting us by completing this questionnaire.
17200 State Hwy 249, Suite 100.Houston, TX 77064
Phone #: 832-463-4526Fax#:832-446-3631
1. What can a Physical Therapy program do for me that I cannot do on my own?
Patients have said, "I have had this before and I know what works for me," or, "I know what is causing this; my neighbor had the same thing so I will just do what she did." A physical therapist is a specialist skilled and educated in identifying and treating mechanical and movement dysfunctions that result in pain. We receive the latest updates on management for different dysfunctions and injuries and we work closely with the
referring physician to develop a rehabilitation program specifically designed for each individual.
No two people are alike. Our trained professionals and support staff will take into consideration your unique
body type, movement patterns, alignment and habits when determining exercises, correction of alignment,
and recommendations on movement patterns.
Because of healthcare guidelines and reimbursement changes, your physician may not have the time
necessary to explain your injury, dysfunction or disability and why or how it occurred. He or she has therefore
referred you to a physical therapist who is specially to educate you on the specifics of your problem and what
the course of action will be to correct it and reduce the chance of a reoccurrence.
2. How long is it going to take?
Factors that influence speed of recovery are: general health, age, other medical conditions, prior injuries,
mental health, presence of life stressors, and what area of your body needs to heal. While we can usually give
a rough approximation at your initial evaluation, we will have a much better impression at your two week
reevaluation. Most problems that we see have taken a long time to develop and will therefore take time to
heal.
Your therapist will give you a home exercise program. This program, as well as attendance at your scheduled
appointments, will take effort and perseverance and also help speed of your recovery.
3. Who benefits from Physical Therapy?
Anyone can benefit, whether you are currently in pain, just looking to become more active, or experiencing
fatigue and weakness that limits your activity. Physical therapists are experts in the neuromusculoskeletal
system and the biomechanics behind how it works. By observing your movement patterns, a physical
therapist can normally identify patterns and habits that make you more susceptible to injury.
Physical therapists are also highly trained in wellness and can provide instruction for developing a healthier
lifestyle that includes beginning or advancing an exercise routine as well as injury prevention.
4. What will I have to do in Physical Therapy?
If your pain is acute and severe, there will be little or no exercises until pain is better controlled. Once your
acute pain is under better control you will start activity that will require physical effort both in the clinic and at
home. This may include training for stability, strength, endurance, flexibility, or balance.
You can expect to do brief, pain-free aerobic activity at the beginning of your visit to the clinic before starting
your normal therapeutic exercises. This warm up is a key component of any active rehabilitation program as it
both maximizes your exercise effectiveness and reduces the chance of further injury.