MS Disease Management Program
July 11th, 2014
Dear Ms. Rene Bersani,
Thank you for scheduling an orientation session with our staff at Total Rehab & Fitness. We are
excited to meet you and introduce our unique Disease Management Program. As you will see,
we offer a holistic approach, incorporating a broad range of programs and services to improve
the quality of your life and help you regain function, reduce hospitalizations and lower health
care costs.
Prior to your visit, it would be very helpful if you could complete the enclosed packet of
information and bring it with you to orientation. We realize it is lengthy, but the sooner we have
your complete medical history, the sooner we can start you on a program to better health.
Please be sure to bring with you your primary health insurance card as well as a photo ID.
If you are unable to complete the paperwork, we will be glad to help you with it when you
come to Total Rehab & Fitness. In the interim, if you have any questions, feel free to contact
Caitlin Buddie, our office administration, at 856-424-5552 or at
administrator@totalrehabandfitness.com.
Thank you for your cooperation, we look forward to meeting you on Tuesday July 22nd at
1:00pm. If you have any questions please do not hesitate to contact us.
Sincerely,
Jared Hoover PT, DPT
Director of Therapy Services
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Patient Registration Form
Patient’s last name:
Is this your legal
name?
First:
If not, what is your legal
name?
Middle
Marital Status:(Circle One)
Single Marr Divorce
Sep Widowed
Social Security #
Best phone number to reach you:
Email Address:
Street Address:
City:
Date of Birth
State:
Zip Code
List current Neurologist:
Neurologist’s Phone # if known:
List current primary care physician:
Primary Care Physician’s Phone # if
known:
Name of local relative or friend:
In Case of Emergency
Relationship to
patient:
Phone #:
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid
directly to Total Rehab & Fitness. I understand that I am financially responsible for any remaining
balance. I also authorize Total Rehab & Fitness to release any information required to process my claim/s.
Patient/Guardian Signature:
Date:
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Patient’s last name:
First:
Today’s date:
DOB:
Official year of your MS diagnosis and who diagnosed you: ___________________________________________
Please briefly explain the reason/s why you have come to TRF:
 ___________________________________________________________________
 ___________________________________________________________________
 ___________________________________________________________________
 ___________________________________________________________________
Family History
Is your father alive or deceased: ______________
Please state, if known, father’s medical history: ____________________________________________________
____________________________________________________________________________________________
Is your mother alive or deceased: ______________
Please state, if known, mother’s medical history:___________________________________________________
____________________________________________________________________________________________
Personal History
Do you currently have pain anywhere? If so please describe the location and frequency: _______________
____________________________________________________________________________________________
____________________________________________________________________________________________
Have you ever had any of the following?
MS exacerbation
Cancer
Tuberculosis
Diabetes
Heart Disease
High or Low Blood Pressure
Stroke
Diabetes type II
Bronchitis, pneumonia, emphysema
Depression or anxiety disorder
Urinary Tract Infections
Hyper or hypothyroidism
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Date of last exacerbation:_____________________
When diagnosed:____________________________
When diagnosed:____________________________
When diagnosed:____________________________
When diagnosed:____________________________
When diagnosed:____________________________
Date of last stroke:__________________________
Do you test your blood sugar:_________________
When diagnosed:____________________________
When diagnosed:____________________________
When diagnosed:____________________________
When diagnosed:____________________________
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Patient’s last name:
First:
Today’s date:
DOB:
Please list other medical conditions that you presently have:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Please check off the immunomodultor you are currently taking and describe any known side effects you may
be experiencing:
□ Avonex ( interferon 1a)
□ Rebif ( interferon 1a)
□ Betaseron( interferon 1b)
□ Copaxone ( glatiramer acetate) □ Gilenya( fingolimod)
□ Aubagio( teriflunomide)
□ Tecfidera ( dimethyl fumarate)
□ Mitoxatrone ( novantrone)
□ Tysabri ( natalizumab)
Side effects you think you may be experiencing from these medications: ________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Are you currently undergoing any monthly or quarterly steroid or chemo infusion? If so please list them:
____________________________________________________________________________________________
Are you currently undergoing plasmaphoresis? If so please list your weekly schedule:
____________________________________________________________________________________________
If possible can you please check off the phase of MS that you think you currently are in:
□ Relapsing Remitting □ Secondary Progressive □ Primary Progressive
□ Relapsing Progressive
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Patient’s last name:
First:
Today’s date:
DOB:
In the next section simply check any condition or symptom that may apply to you
Arthritis or
Rheumatitis
Any bone or joint
disease
Bursitis or Sciatica
Anemia
Blood Clots
Foot Pain
Pins and needle
sensation anywhere
Low Back Pain
Kidney Disease
Liver Disease
Colitis or Bowel
Disease
______
Mental Health
Disorder
______
Frequent
Headaches
______
______
______
______
Short of breath
walking 2 blocks
______
______
Short of Breath
with steps
______
Dizziness with
postion change ______
Purple lips or
fingers
______
Blurred Vision
Double Vision
______
Swelling in legs
______
or arms
______
Leg Cramps
with walking
______
Joint/s
Swelling
______
______
Chest Pain
______
______
Heart
Palpatations
______
Muscle Spasms ______
______
Growth in neck
______
or throat
______
Recent Loss of
weight
______
______
Fever /sweating
in bed
______
______
Inabilty to stand
heat/cold
______
______
______
Blood in Saliva
Pain in Arm/s
______
Chronic Cough
______
Wake up Short
of Breath
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Patient’s last name:
First:
Today’s date:
DOB:
Please list the month and year of your last physical examination by a primary care physician: ______________
Please list date of last MRI: ___________ Have you recently had a stress test? If so when: __________________
Have you recently had a blood testing done: ________ Have you injured yourself from a fall recently: ________
Are you Experiencing Difficulty with any of the following? Check all that apply:
Short/long Term
Memory
Organizing your
Thoughts
Eating/swollowing
(coughing/choking)
Balance/mobilty effect
abilty to get on/off
toilet
Balance effect abilty to
get in/ out of
bathtube/shower
Feeling down,
depressed or hopless
______
Articulation/slurred
speech
______
Keeping Attention
______
Difficulty with writing
______
Issues manipulating
buttons/zippers/laces
______
Decreased sensation
in hands
______
Experience bouts of
severe anxiety
______
Expressing your
thoughts
______
______
Understanding language
when spoken
______
______
Self Grooming/ getting
dressed
______
______
Difficulty with lower
body dressing
______
______
Fatigue interfere with
daily activites
______
______
Little interest or
pleasure in doing things
______
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ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE
I acknowledge that I have received the Notice of Privacy Practice
__
Signature of Patient or Legal Representative
Date
Relationship to Patient
TRANSMISSION OF MEDICAL RECORDS
I give Total Rehab & Fitness permission to communicate and transfer medical documents with
other indicated health care professions.
_____________________________
_____________________
Signature of Patient or Legal Representative
Date
CONSENT FOR CARE & TREATMENT
I, the undersigned, do hereby agree and give my consent for Total Rehab & Fitness
to furnish care and treatment and consider this medically necessary to prevent further decline and
improve my current physical, cognitive and or emotional state.
Signature patient/guardian: _____________________________________ Date: ______________
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Notice of Privacy Practices
This privacy notice is being provided to you as a requirement of a federal law, The Health
Insurance Portability and Accountability Act (HIPAA). This notice of privacy practices
describes how we may use and disclose your protected health information to carry our
treatment, payment or health care operations and for other purposes that are permitted or
required by law. It also describes your rights to access and control your protected health
information. Your “protected health information” means any written and oral health information
about you, including demographic data that can be used to identify you. We are required by
Federal law to give you this Notice and to maintain the privacy of your health information.
Please review it carefully.
I.
How We May Use and Disclose your Protected Health Information
When we give you our Notice of Privacy Practices, you will be asked to sign an
Acknowledgement of Receipt. Once you have received our Notice and signed the
Acknowledgement, we will use your protected health information for treatment, payment and
health care operations. We may use or disclose your protected health information in an
emergency treatment situation. If this happens, we will try to obtain your signature on the
Acknowledgement of Receipt as soon as reasonably possible after the delivery of treatment. The
following examples show the types of uses and disclosures of your protected health information
that our office is permitted to make.
A. Treatment: Your protected health information may be used and disclosed by our
office and others outside of our office that may be involved in your medical care. We will
use and disclose your protected health information to other physicians to provide,
coordinate, or manage your health care. For example, your protected health information
may be provided to another physician or specialist to whom you have been referred to
ensure that the necessary information is available to diagnose or treat you.
B. Payment: Your protected health information may be used and disclosed to pay your
health care bills. Your protected health information will be used to obtain payment for
services we provide to you. This may include certain activities that your insurance plan
may undertake before it approves or pays for the services we recommend.
C. Healthcare Operations: We may use or disclose your protected health information in
order to support the business activities of our practice. Healthcare operations include
quality assessment activities, employee review activities, licensing or credentialing
activities, conducting training and conducting auditing or review activities. For
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example, we may send you reminder postcards or telephone you to remind you of an
appointment. We may also send you a newsletter about our practice and the services
we offer. You may contact our Privacy Officer to request that these materials not be
sent to you.
D. Business Associates: We will share you protected health information with third
party business associates that perform various activities for our practice. Whenever
we disclose you protected health information to a business associate we will have a
separate “authorization to release protected health information” form that will be
signed by
you. For example, we may disclose pertinent medical information to personal trainers
or dieticians for the purpose of designing a regime that is specific to you, safe for you,
and within your medical parameters.
II.
Use and disclosure permitted without authorization but with opportunity to object
Family members and friends: Unless you object, we may disclose to your family member, a
relative, a close friend or any other
person you select, your protected health information to the extent necessary to help with you care
of with payment for the services
we have provided. We will also use our professional judgment and common practice to make
reasonable decisions in your best interest in allowing a person to pick up medical supplies, xrays, prescriptions or other similar forms of health information.
III.
Other disclosures that may be made without your authorization
A. Required by law: We may use or disclose your protected health information when
we are required to do so by law.
B. Abuse or Neglect: We may disclose your health information to appropriate
authorities if we reasonably believe that you are a possible victim of abuse,
neglect or domestic violence or the possible victim of other crimes. We may
disclose you health information to the extent necessary to avert a serious threat
to your health or safety or that of other persons.
C. Military personnel and national security: We may disclose the health
information of Armed Forces personnel when requested by command military
authorities. We may disclose to authorized federal officials health information
required for lawful intelligence, counterintelligence and other national security
activities.
D. Worker’s Compensation & Health Oversight Activities: We may disclose your
protected health information to comply with worker’s compensation laws and to
health oversight agencies when conducting investigations or inspections as
authorized by law.
E. Required uses and disclosures: Under the law, we must make disclosures to
you and when required, to the Department of Health and Human Services when
determining our compliance.
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IV.
You have the following rights
A. Inspect and copy your protected health information. You have the right to
look at or get copies of your health information, with limited exceptions. You
may request that we provide copies in a format other than photocopies. We will
use the format you request unless we cannot practically do so. You must make
the request in writing to obtain access to your health information. You may
obtain access by sending a letter to our Privacy Officer listed at the end of this
notice.
B. Request a restriction of your protected health information. You have the
right to request that we place additional restrictions on our use or disclosure of
your health information. We are not required to agree to these additional
restrictions, but if we do, we will abide by our agreement, except in an
emergency.
C. Request an amendment of your health information: You have the right to
request that we amend or correct your health information. Your request must be
in writing. The request must explain why the information should
be amended or corrected. We may deny your request under certain situations.
D. Receive an accounting of disclosures we have made of your health
information. You have the right to an accounting of disclosures of your health
information that occurred after September 1, 2008. This accounting will
be for purposes other than treatment, payment or healthcare operations, or
disclosures we may have made to you, to your family members or friends
involved in your care. The right to receive this information is subject to some
exceptions.
E. Make a complaint about our privacy practices. If you are concerned that we
have violated your privacy rights, you may file a complaint with our Privacy
Officer using the contact information listed at the bottom of this page. You may
also file a written complaint with the Department of Health and Human Services.
We will provide you with their address upon request. We will not retaliate
against you for making a complaint or change the way we treat you.
F. Request to receive confidential communications from us by alternative
means or at an alternative location. You have the right to request that we
communicate with you in certain ways. We will accommodate reasonable
requests. We may condition this accommodation by asking you for information
as to how payment will be handled or specification of an alternative address or
other method of contact. We will not require you to provide an explanation for
your request. Requests must be made in writing to our privacy officer.
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V. Our duties
The facility is required by law to maintain the privacy of your health information and to
provide you with this Privacy Notice of ourduties and privacy practices. We are required
to abide by terms of this Notice and to make the new Notice provisions effective for
all future protected health information that we maintain. If the facility changes its Notice,
we will provide a copy of the revised Notice by sending a copy of the revised Notice via
regular mail or through in-person contact.
VI. Contact Person
The facility’s contact person for all issues regarding patient privacy and your rights under
the federal privacy standards is the Privacy Officer. Information regarding matters
covered by this Notice can be requested by contacting the Privacy Officer. If you feel that
your privacy rights have been violated by this facility you may submit a complaint to our
Privacy Officer by sending it to:
ATTN:
Director of Therapy Services
Total Rehab & Fitness
1111 Marlkress Rd, Suite 103
Cherry Hill, NJ 08003
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MEDICATIONS LIST
PATIENT NAME:
DOB:
Prescription
Daily Doses
Prescribing Physician
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