Patient Information Record

Instructions: Please print and complete this form and bring it with you to your first appointment. If you prefer to fill out the form at our office, please arrive 30 minutes prior to your scheduled appointment time. Please bring your photo ID, Physician referral and Insurance card. Thank you. We look forward to seeing you. Patient Demographics Patient Name: _____________________DOB: _________Age: ______ SS#: _________________ Address: ________________________________ City: __________ State: ____ Zip: _________ Home Phone: _____________ Work Phone: _____________ Cell Phone: ________________ Email: _______________________________ Marital Status: M/S/D/W Sex: M F Emergency Contact: _______________________ Relationship: ____________ Phone: ___________ (If Minor) Responsible Party: ______________________________ Phone: ________________ Address: ______________________________________________________________________ Injury Information: Type of Injury: Work Non-Work Motor Vehicle Diagnosis: _____________________________________________________ MD: _______________________ MD Phone: ______________ MD Fax Number: _____________ Date of injury: ___________ Date of surgery: _____________ State Injury Occurred In (if other then AZ): _________ Employer Information: Employer: _______________________________ Employer Address: _________________________________ Employer Phone: __________________ Insurance Information:
Primary Ins Ins Company ID # / Claim # Group # Ins Co Phone # Authorization # Primary Card Holder Secondary Card Holder Attorney Address Primary DOB Secondary DOB Primary SS# Secondary SS# Phone # Secondary Ins Work Compensation

Authorization To Release Information: I hereby authorize the release of any medical information necessary to process my claims. In the event that a dispute arises regarding non-payment for services between my provider and my insurance company, I give my permission for the AZ Department of Insurance to access my medical records if necessary to resolve the matter. I understand I am financially responsible for non-covered or denied services, including collection fees if necessary. Signed: __________________________________________________ Dated: ___________________

This form is to inform you the patient of the procedures of that MAY be done as part your treatment Modaility/Procedure Cryotherapy Normal/Expected Reaction Intense cold Burning Numbness Tingling Skin redness Warmth Cold Numbness Pain Skin redness Burning Mild Warmth Tingling

Tucson Physical Therapy Modality Checklist

Abnomal Reactions Nerve hypersensitivity Sudden Pallor Hypersensitivity Blistering Nerve sensitivity Blistering Extreme burning sensation Thrombophlebitis Bone Demineralization Growth plate damage Tissue cavitation Redness Hypersensitivity Skin irritation from pad adhesive Abnormal redness Burns Blistering Shock Bruising Increase pain Increase symptoms Cyanosis Blistering Pain Burning Expected Benefits Control Inflammation Facilitate movement Increase Circulation Decrease pain Decrease pain Decrease edema Reduce spasticity Improve soft tissue mobility Increase Range of motion PT
(initial)

Pt.
(initial)

Superficial Heat

Contrast Bath

Ultrasound

Discomfort Shock Pain Pain Shock Burns Allergic reaction to medication or pad adhesive Skin irritation Redness

Decrease pain Decrease edema/swelling Desensitization Improved Blood Flow Improved Soft Tissue and joint mobility Reduced pain

Electrical Stimulation

Iontophoresis

Tingling Involuntary muscle Delayed contraction onset muscle soreness Skin redness Minor skin irritation

Reduce Pain and Improve muscle muscle spasm recruitment Improve blood Muscle re-education flow Reduce pain Reduce tissue inflammation Improve cell membrane permeability Improve blood flow Reduce pain and muscle spasm Improve soft tissue mobility Improve range of motion Increase collagen extensibility Improved range of motion Reduced pain Decrease muscle spasms Increase range of motion Decrease in radicular symptoms and pain Improved muscle function and endurance Improved muscle recruitment Increase muscle tone and range of motion

Soft Tissue Mobilization/Massage

Skin discoloration Temporary increase in pain Mild warmth Increase pain Skin discoloration Soft tissue stretch Relieve pressure Muscle relaxation Temporary muscle soreness Fatigue

Joint Mobilization

Mechanical Traction

Therapeutic Exercise

Increased pain or symptoms Loss of range of motion Bruising Soreness 1-2 days after Respiratory restriction Headache Muscle soreness Increased pain and/or symptoms

I have been informed of the above information and have had the opportunity to ask any questions in regards to the above information. I understand that I should notify a staff member immediately if I have any abnormal reactions or pain with any of the above modalities, exercises or with the use of exercise equipment. Patient Signature: __________________________ Date: ____________ Therapist Signature:______________________________

Tucson Physical Therapy, P.C. Medical History

Patient Name: ______________________ Date: _______________ Primary Care Physician: _________________ Referring Physician: ______________ Have you had surgery for this injury: Yes No Type of surgery: __________________ Date(s) of surgery for this injury: ____________________________________________________
Which of the following medications have you taken in the last week? If you have a prepared list please provide so that we may add it to your chart ***If you have any concerns regarding your Physician Not Prescribed Prescribed by Physician medications please refer your questions to your physician Aspirin Tylenol Anti-inflammatories (Circle appropriate) (Advil/Motrin/Ibuprofen/Aleve etc.) Blood Pressure medications Allergy Medication Vitamins/mineral supplements Herbals/Remedies Other medication not listed above:

Dosage

Frequency

Any other physician prescribed medication (including pills, injections, and or skin patches)

Have you had any of the following interventions for this injury?
Urgent Care/ER X rays MRI / CT Scan EMG/Nerve Conduction Test Neurologist Orthopedist/Specialist Physical Therapy Occupational Therapy Chiropractor Other:

Do you have or have you ever been treated for any of the following conditions:
Anemia Allergies Arthritis Asthma Back Injury Blood Clots Cancer Diabetes Dizziness Epilepsy/Seizure Disorder Headaches Heart Disease Hernia High Blood Pressure Internal Difibulator / Pacemaker Cholesterol Joint Replacement Neck Pain Numbness Osteoporosis Sleeping Disorder Vision Problem Weakness Weight Loss Are you Pregnant? Do you smoke? Other Medical Conditions/Surgeries:

Patient Name:

______________________________

DOB:

______________

Please indicate below where your symptoms are located by using the following symbols for the conditions you were referred to physical therapy for:

Numbness Pins and needles Burning Stabbing/Sharp Ache

111111 000000 XXXX /////////// ^^^^^^

Please rate your Pain Level (0-10) 0 = No pain 10 = Emergency Room pain

Now: 0 1 2 3 4 5 6 7 8 9 10 Highest in past week: 0 1 2 3 4 5 6 7 8 9 10 Lowest in past week: 0 1 2 3 4 5 6 7 8 9 10

What activities or positions improve your pain: __________________________________________________________________________________________ __________________________________________________________________________________________ What activities or positions worsen you pain: __________________________________________________________________________________________ __________________________________________________________________________________________ Does your pain that limits your ability to sleep through the night: YES NO How many hours are you able to sleep: ______ hrs

I have reviewed the patients medical history with him/her.

Therapist Signature: _____________

***The therapist and myself have reviewed my medical history. We have discussed the risks and benefits of physical therapy and the modalities used (ie: ultrasound, heat, ice, electrical stimulation). I hereby give my consent to receive treatment from Tucson Physical Therapy

Patient Signature: ___________________________

Print Name: First_Name Last_Name

Tucson Physical Therapy Patient Information Consent Form

I have read and fully understand Tucson Physical Therapys Notice of Information Practices. I understand that Tucson Physical Therapy may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment evaluating the quality of services provided and any administrative operation related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operation if I notify the practice. I also understand that Tucson Physical Therapy will consider requests for restriction on a case by case basis, but does not have to agree to request for restrictions. I hereby consent to use and disclosure of my personal health information for purposes as noted in Tucson Physical Therapys Notice of Information practices. I understand that I retain the right to revoke this consent by notifying the practice in writing at any time.

Information and Designated Individuals Authorization Form

I hereby authorize one or all of the designated parties below to request and receive the release of any protected health information regarding my treatment, payment or administrative operations related to treatment and payment. I understand that the identity of designated parties must be verified before the release of any information. Patient Signature: ______________________________ Dr: __________________________ Insurance Company: _______________________________ For the following purposes: Medical history and billing. Authorized Designees: Name: ______________________________________ Name: ______________________________________ Name: ______________________________________ Name: ______________________________________ Relationship: ____________________ Relationship: ____________________ Relationship: ____________________ Relationship: ____________________ Date: ____________________

I understand that the information outlined in this release will be disclosed according to the instructions of this release within two (2) business days of Tucson Physical Therapy having received this release authorization. I understand that I am free to revoke this release authorization at any time by notifying the practice in writing. I also understand that the information disclosed under is release is subject to re-disclosure and no longer protected by the Privacy Regulations (45C.F.R. 164). Patient Name: _________________________________ Patient Signature: ______________________________ Date: ____________________

Tucson Physical Therapy To Our New Patients:

Welcome to Tucson Physical Therapy! To ensure that you have a pleasant experience and receive the best possible care, please follow the guidelines below. We look forward to working with you.

1. We prefer you wear or bring comfortable clothing such as, a T-shirt, shorts/sweats, tennis shoes (comfortable flat-heeled shoes). We will provide a place for you to change. 2. Please provide an accurate history. Good communication is an essential component to the therapy process. 3. When you arrive at Tucson Physical Therapy, please sign in. This must be done for each visit. If you dont sign in, we may not know that you are waiting. 4. Please keep your appointments. This is very important to achieve your goals. We along with your physician have given time and thought to your treatment plan, but it will not work if you are not here. 5. If you cannot keep an appointment, or think you might late, please call. We may be able to schedule you at a later time if our schedule permits. If you need to cancel please give a 24 hour notice or you may be charged a $25.00 late cancellation fee which is not reimbursable by insurance. 6. If you miss 2 appointments without calling, we will cancel all remaining therapy appointments and you must see your physician before returning to physical therapy. 7. Please be on time for your appointments. If you are more than 15 minutes late, you may have to reschedule. We attempt to follow our appointment schedule closely, so if you arrive early you may have to wait until your appointment time, but we will make every effort to see you as soon as possible. 8. We deal with many different insurance companies, all of which have their own guidelines. There may be specific guidelines for physical/occupational therapy services under your policy. It is helpful to know what your specific benefits are so that we can bill your insurance appropriately and minimize any out of pocket expenses other than what is outlined on your verification sheet. If you have any questions regarding your specific benefits please feel free to contact our billing office and they would be happy to help you: 520-747-9225.

Thank you for allowing Tucson Physical Therapy to serve you. Our physical therapists and their staff will endeavor to provide you with quality care following the highest standards of practice as established by the American Physical Therapy Association.