Private Insurance/Cash Pay Patient Information
Name Date
Mailing Address City: Zip:
(It is important that you supply a MAILING address if different from physical address)
Home Phone# Cell#: Work Phone# Email______
Would you like email reminders for appointments ___Yes___No
SS # - - Birth date
Age Sex
Referring Physician
Primary Physician
*****************************************************************************************Employment Information
Occupation
Employer Name
Employer Phone Number
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Emergency Contact
Name Phone
Relationship
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This note is effective as of: 09/23/2013
My signature below indicates that I have been given the opportunity to read the PASO ROBLES PHYSICAL THERAPY NOTICE OF PRIVACY PRACTICES. I provide Paso Robles Physical Therapy with my authorization to use and disclose my protected health care information for the purposes of treatment, payment and health care operations as described in the privacy notice .I hereby authorize and instruct my insurance company to pay directly to PASO ROBLES PHYSICAL THERAPY medical benefits otherwise payable to me, and will be responsible to PASO ROBLES PHYSICAL THERAPY for all expenses incidental to treatment rendered, not paid under this plan, unless otherwise arranged with TONY WALLACE PT.
Signature of Patient Date
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Cash Pay Patients not covered under insurance coverage:
I do not have insurance that will cover Physical Therapy treatment. I plan to make payment to Paso Robles Physical Therapy as follows:
( ) Cash/Check per visit ( ) Special arrangement made in advance of treatment
______
Signature of Patient Tony Wallace or Office Staff Date
Patient Medical History
Name Date
PLEASE COMPLETE ALL REQUESTED INFORMATION
1) Have you ever had physical therapy for the same condition for which you are here today? If so, where and when?
How did you find out about Paso Robles Physical Therapy?
2) Please List your: Height: Weight: Age: Date of Onset: Date of Surgery-
3) Briefly describe your present accident, injury or illness:
4) List any medications you are now taking (please let the office know if you have a list to copy)
5) Please list any recent diagnostic studies (eg. X-ray, MRI, CAT scan, blood work) particularly as related to your present problem and where taken
6) Do you have metal anywhere in your body, i.e. pins, plates, pacemaker, etc (except teeth)? If yes, please describe
7) Are you now pregnant? YES NO 8) List any allergies you have
9) List any surgeries with approximate dates
10) Circle any medical conditions we should be aware of: High blood pressure Seizures Diabetes
Heart or circulation disorders Dizzy spells Arthritis/osteoarthritis Osteoporosis Cancer Pacemaker
Breathing Difficulties Thyroid Other or explain the above:
11) On the body diagram to the right, please indicate where your pain is located at the present time. Please do not indicate areas of pain that are not related to your present injury or condition.
12) Indicate on the line below how you would describe your present pain by placing a mark on the line between the two extremes of experiencing no pain at all and experiencing the worst pain you have ever felt.
None Worst imaginable