Name
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First Name
Last Name
Date of Birth
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MM
DD
YYYY
Email
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Phone: Cell / Home
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(###)
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
How did you find out about me? Who referred you?
Primary Complaint:
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When did you complaint first occur?
What seems to make your complaint feel worse?
What seems to make your complaint feel better?
Is your complaint worse in the:
Morning
Evening
Please list any treatment you have had and/or are currently receiving for this condition?
Please check all that you have experienced in the past 6 months.
Please check all areas you have issues with.
How else does your condition affect your day to day living? BOTH at Home and at Work.
Describe what / how your complaint is preventing you from doing or enjoying the things that matter to you so that I can help you feel better and move better.
Current Medications / Supplements
Current Health / Medical Conditions
(High Blood Pressure, Cholesterol Issues, Diabetes, Auto-Immune Problems, etc.) Please be honest and include all conditions. Many patients fail to realize how "unrelated" issues are actually related to their problem and may slow down positive results if not shared early in the treatment.
Surgeries / Hospitalizations / Injuries (from the past 3 years)
Please be honest and include all conditions. Many patients do realize how "unrelated" past issues are actually related to their problem and may slow down results if not shared.
Type / Frequency of Exercise /Hobbies / Other Activities
PATIENT CONSENT & SIGNATURE By you agreeing below, you acknowledge that you have read and understand the information below, and that you have had the opportunity to request or view, or do not wish to request or view this office’s HIPPA policies. A reproduction/copy or email of this document shall be considered as effective and valid as an original. Authorization may be denied or retracted by notifying in writing to the Doctor. You authorize the doctor and his staff to release or request any information deemed appropriate concerning your physical condition to any third party payer or healthcare provider, or legal guardian in order to process any claim for reimbursement or charges incurred by you as a result of professional services and or products rendered and hereby release the doctor of any consequences thereof or to continue or provide necessary information to assist in the treatment, management, or collection of/for your case or condition. (The last sentence says you give us permission to talk to whomever we need to – to help manage your bill or care.) Your agreement serves as receipt of “signature on file" for the request of any records needed to facilitate your care or charges. If the above patient is a MINOR: You, being the parent, legal guardian or custodian, do hereby authorize, request and direct the facility and staff to perform examinations, diagnostic tests, and any treatment that in their judgment, is deemed clinically necessary. You confirm you have the authority to sign this form, and no other person is required before care can be given. You continue to give us the right to care for the minor until he/she has attained legal age. You acknowledge that you are wanting to be examined and/or treated by this office and give permission to perform the necessary test and exams, as well as treatments required to accomplish this task. This form stands as notification that all procedures performed in a healthcare office, including this office, have a risk associated with their administration. As in all physical medicine/therapy clinics - known risk include, but are not limited to the possibility of fracture, dislocation, soft tissue damage, stroke, or arterial dissection, which may be the result of testing, treatment, trivial movement, or unrelated to the care provided. You are encouraged to request further information, and possible risk that may affect you specifically. Failure to disclose known personal or family health issues, even if you don't consider them relevant, may expose you to greater risk and acceptance of liability. You understand that you are financially responsible for any and all services provided at this office - regardless of effectiveness or outcome. Our office and staff are committed to providing all patients regardless or race, color, national origin, age, sex, disability or religious or political beliefs, quality healthcare services delivered with dignity and concern. As a wellness based provider, I do not participate with or bill any insurance company, including Medicare, for the care provided at this office. Additional, I do not provide diagnosis or procedure codes for submission for reimbursement.
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Yes - I agree. This serves as my digital signature.