new patient form - Zenergy Physical Therapy

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NEW PATIENT INFORMATION
NAME: _____________________________________
GENDER: F / M
DOB: _____________
ADDRESS (include city and Zip code):
_____________________________________________________________________________________
_____________________________________________________________________________________
PHONE: _______________________________________________________________
EMAIL: _______________________________________________________________
PRIMARY DOCTOR: ___________________________________________________
REFERRED BY: ________________________________________________________
Check here if Paying Out of Pocket _____
Fill out information below if you are paying through insurance
INSURANCE INFORMATION (if applicable)
NAME of INSURANCE Company : __________________________________________
INSURED NAME (AS IT APPEARS ON CARD) _____________________________
POLICY # ______________________________________________________________
GROUP # (IF APPLICABLE): ____________________________________________
TELEPHONE CONTACT NUMBER (FOR PROVIDERS): ___________________
NAME OF PRIMARY INSURED (IF MILITARY): __________________________
DOB and SS# of PRIMARY (IF MILITARY) _________________________________
SECONDARY INSURANCE (if applicable): __________________________________
POLICY # ______________________________________________________________
TELEPHONE CONTACT NUMBER (FOR PROVIDERS): ___________________
Patient Medical History and Health Risk Profile
Patient Name:
Age:
Emergency contact:
Date:
Height:
Weight:
Name:
Phone:
Relationship:
1) Problems to be treated today:
Have you had treatment for this problem before? (
) Yes
(
) No
When :
Please describe the type of treatment:
Have you had surgery associated with this problem? ( ) Yes ( ) No
If so, please list date and type:
2) Do you have any other condition that is aggravated by exercise?
3) Please list the names of any primary care physician / internist / cardiologist that you are seeing:
Name:
Name:
Phone:
Phone:
4) Are you currently pregnant? (
) Yes
(
) No
5) Do you need assistance with any of the following:
Transportation
Yes
No
Meals
Yes
No
Shopping/Errands
Yes
No
Personal Care
Yes
No
Domestic chores
Yes
No
Other
Yes
No
6) Has your illness / disability caused any of the following:
Financial Problems
Yes
No
Family Problems
Yes
No
Emotional Problems
Yes
No
Other
Yes
No
Osteoporosis
Yes
No
7) Do you have or have you had any of the following:
Feel faint or dizzy
Yes
No
Known heart disease
Yes
No
Frequent pain in heart or chest
Yes
No
Diabetes
Yes
No
Pacemaker
Yes
No
Swollen ankles
Yes
No
Headaches
Yes
No
Kidney problems
Yes
No
Nervous disorders
Yes
No
Heat sensitivity
Yes
No
Allergies
Yes
No
Hernia
Yes
No
Seizures
Yes
No
Metal implants
Yes
No
Balance problems
Yes
No
Vision problems
Yes
No
Hearing Problems
Yes
No
High blood pressure
Yes
No
High cholesterol
Yes
No
Low blood pressure
Yes
No
Cancer
Yes
No
Tuberculosis
Yes
No
Hepatitis
Yes
No
>50
8) Please circle the closest answer or leave item blank if you do not know:
Cigarettes (per day)
Never
1-5
10-20
30-40
Alcoholic drinks (per week)
Never
1-5
10-20
>20
Cardiovascular Fitness (per week)
None
Occasional/
3+ days/week for
Recreational
at least 15 minutes
9) Respiratory Status:
Normal
Moderate
Severe (shortness of breath with mild exertion)
Comprehensive Intake Form
Name:___________________
Chief Concerns: (Main reasons for seeking consult)
_____________________________________________________________________________________
___________________________________________________________
Duration and Frequency of Symptoms:
________________________________________________________________________
History of any serious illness and all surgeries: (continue on back if needed)
_____________________________________________________________________________________
_____________________________________________________________________________________
Current Medical Conditions:
__ Arthritis
__ Osteoporosis __ Diabetes
__ Hypertension __ Cancer
__ Other: _____________________________________________________
PLEASE CHECK IF ANY THE FOLLOWING APPLY TO YOU:
VATA
__ Dryness
__ Insomnia
__ Gas
__ Bloating
__ Constipation
__ Hemorrhoids
__ Muscle: Twitch, cramp,
numb, weakness
__ Joint pain or cracking
__ Stiffness
__ Shifting or tearing pain
__ Dry cough
__ Cold extremities
__ Dry skin
__ Restlessness
__ Worry, fear, anxiety
PITTA
__ Diarrhea
__ Loose Stool
__ Nausea
__ Migraines
__ Vomiting
__ Skin conditions:
Rash, acne, hives, boils
__ Bruising
__ Excess thirst
__ Burning, sharp pain
__ Spontaneous bleeding
__ Tender to touch
__ Excess body heat
__ Interrupted Sleep
__ Anger, rage, or envy
__ Judgemental, critical
AMA (IMBALANCE)
__ Coating on tongue
__ Low grade fever
__ Excess sleep
__ Aches and pains
__ Malaise
__ Lethargy
__ Lack of Energy
__ Lack of Appetite
__ Sinking Stool
__ Difficulty creating the life you want
KAPHA
__ Congestion
__ Food or respiratory
allergy
__ Edema
__ Heaviness
__ Dullness
__ Dull, vague pain
__ Cold, clammy hands
__ Difficulty sweating
__ Frequent urination
__ Excess oily skin
__ Excess sleep
__ Depression or greed
__ Attachment
__ Mental lethargy
GENERAL
__ Digestive Disturbance
__ Low appetite
__ Sleep disturbance
__ Menstrual disturbance/imbalance
__ Lack of energy
__ Throat/eyes/ears problems
__ Chest/lung/heart problems
__ Urine: difficulty, burning, or cloudy
__ Headaches
__ Pregnant or __ Menopause
__ other _________________
PLEASE CHECK IF ANY THE FOLLOWING DESCRIBE YOUR PAIN/DISCOMFORT:
VATA
__ Shooting
__ Throbbing or pulsating
__ Radiating
__ Fluctuating
__ Migrating
__ Stiffness
__ Numb or tingling
__ Muscle weakness
__ Low back or buttock
__ Worse if weather change
PITTA
__ Burning
__ Sharp
__ Nauseating
__ Pulling
__ Tender
__ Pain with pressure
__ Irritated with sneeze or
couch
__ Worse in heat or midday
KAPHA
__ Congestive pain
__ Dullness
__ Static pain
__ Heaviness
__ Swollen
Please check the areas where you are most interested in improving your health.
If you are currently doing anything currently in any areas, please describe: (use back if needed)
__ Exercise: _____________________________________________________________
__ Diet/nutrition: _________________________________________________________
__ Meditation/Self awareness: _______________________________________________
__ Yoga/pilates: __________________________________________________________
__ Breathing: ___________________________________________________________
__ Bodywork/massage: ____________________________________________________
__ Herbs/supplements: _____________________________________________________
__ Daily routine: _________________________________________________________
__ Community involvement: ________________________________________________
__ Spiritual: _____________________________________________________________
Describe your goals and what you would like to accomplish with Physical Therapy
_____________________________________________________________________________________
___________________________________________________________What do you believe to be the
greatest barrier to your vision and goals?
________________________________________________________________________
What do you believe you or others can do to help best facilitate your wellness/recovery?
_____________________________________________________________________________________
___________________________________________________________
Is there anything else that you would like to share?
_____________________________________________________________________________________
___________________________________________________________
Financial and Treatment Policy
1. Advance payment is due prior to services rendered. Payment may be made in cash, check, or credit
card. As a courtesy, Zenergy will file an insurance claim on your behalf to your insurance company. By
signing below you grant Zenergy Physical Therapy permission to submit claims and receive payment on
your behalf. This does not guarantee payment. Ultimately, you are responsible for any unpaid balance on
your account for services rendered at Zenergy Physical Therapy. For individuals utilizing Health
Insurance Benefits we strongly encourage you to call your insurance company to verify your benefits and
what your financial responsibilities are for Physical Therapy.
2. All Physical Therapy treatments are about 45 minutes in duration.
3. Please arrive fragrance free to eliminate possible allergic reactions.
4. Clothing should be comfortable and free to move in.
5. Scheduled appointments need to be canceled the day prior to your appointment
to avoid $50 charge. You will be allowed 1 same day cancellation without incurring a charge. No
shows (without calling to cancel) will incur a full charge for the missed appointment.
6. As a courtesy please turn off your cell phones or pagers unless there is an emergency.
7. You may inquire about discounts for cash payments and packages.
8. Purchased cash packages will expire in 3 months of purchase, unless other arrangements have been
agreed upon. Once you pay for a package, there will be no refund offered.
9. By signing below you acknowledge that you have been advised to obtain medical clearance for
physical exercise and activity by your health care provider/Medical Doctor.
10. Zenergy Physical Therapy, Inc. is not liable for any injury sustained during Physical Therapy
treatments.
______________________
Signature:
Thank you kindly for your business!
_______________________
Date
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