PATIENT
INFORMATION
Primary Care Physician:
__________________________
Today’s date:
PATIENT INFORMATION
Patient’s last name:
Is this your legal name?
 Yes
First:
Middle:
If not, what is your legal name?
Marital status (circle one)
Single / Mar / Div / Sep /
Wid
Birth date:
Age:
Sex:
 Mr.  Miss
 Mrs.  Ms.
(Former name):
 No
/
Street address:
Social Security no.:
City:
State:
 MD
Who referred you:
How would you like your
reminder calls?
Family/Friend
Name:
Voice Call  Text  Email _____________________________________
 No
INSURANCE INFORMATION
(Please give your insurance card to the receptionist.)
Birth date:
If YES, Date Of Injury:_____________________________
Address (if different):
Home phone no.:
/
/
Is this person a patient
 Yes  No
here?
Occupation:
Employer:
Employer address:
(
Is this patient covered by
 Yes  No
insurance?
Please indicate primary
 Blue Cross
 Blue Shield
 Aetna
insurance
 Cigna
 HealthNet
 TriWest
 United HealthCare
Subscriber’s S.S. no.:
Birth date:
/
Patient’s relationship to subscriber:
Name of secondary insurance (if
applicable):
 Self
Patient’s relationship to subscriber:
 Self
 Spouse
Group no.:
 Child
 VA
 Other
Policy no.:
Co-payment:
$
 Other
Group no.:
 Child
)
 Workers Comp
/
Subscriber’s name:
 Spouse
)
Employer phone no.:
(
Subscriber’s name:
)
ZIP Code:
Were you injured on the job?  Yes
Person responsible for bill:
F
Home phone no.:
(
P.O. box:
M
/
Policy no.:
 Other
IN CASE OF EMERGENCY: ______________________________Contact Phone:____________________________
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I
understand that I am financially responsible for any balance. I also authorize [Name of Practice] or insurance company to release any
information required to process my claims.
Patient/Guardian signature
Date
1|Page
PATIENT INFORMATION RECORD
Type of work, examples: lifting, prolonged sitting, standing, keyboarding, etc.
Please describe character of your current pain. (You may check more than one answer)
Sharp Stabbing Burning Dull Aches Tingling Numbness Soreness Weakness Shooting Throbbing
How often are the complaints?
Constant (70-100%) Frequent (51-75%) Occasional (26-50%) Intermittent (25%)
Please rate the severity of your pain. (Please circle a number below) 0 = No Pain
CURRENT
0 1 2 3 4 5 6 7 8 9 10
BEST
0 1 2 3 4 5 6 7 8 9 10
WORSE
10 = Unbearable pain
0 1 2 3 4 5 6 7 8 9 10
Since your problem started, is the pain: Increasing Decreasing Not Changing
Do your symptoms change throughout the day? YES NO
Problem began: Immediately after trauma or specific incident Multiple incidents Developed over time
What aggravates your symptoms?
What treatment have you received for this present condition? Surgery Spinal Injection Physical Therapy
Chiropractor None Other
Have you ever had similar episodes before? YES NO
Have you, or are you currently being treated by another healthcare practitioner for this problem? YES NO
If yes, by: Chiropractor MD Other
Have you had any of the following? X-Ray MRI CT Scan EMG Myelogram Discogram
Have you had any changes in bowel or bladder function? YES NO
Do you have fever, chills, or night sweats? YES NO
Describe daily activities:
Present:
Desired
Please indicate location of symptoms on illustration:
2|Page
INSURANCE AND FINANCIAL INFORMATION
Please read the following carefully: INSURANCE IS NOT A SUBSTITUE FOR PAYMENT:
Call you insurance company if you have any questions. You are ultimately responsible for payment for any services
rendered that are not paid by your insurance company.
Private Insurance: You are responsible for your deductible, and co-payment, at the time of service. INDIVIDUALIZED
PHYSICAL THERAPY will verify eligibility of benefits of your private insurance and inform you of your financial responsibility
at your visit. Once your insurance company has paid their portion, you will receive an invoice for any remaining balance. If
you wish us to bill a secondary insurance you must provide us both cards at the first visit. In order to avoid delays on
insurance reimbursements, please immediately inform the office staff of any change of insurance plans.
Medicare: The Medicare cap for non-exempt diagnosis is $1920.00 currently. Medicare covers 80% of approved charges
for out-patient physical therapy services, (combined w occupational, speech, and rehab therapies) provided that your annual
deductible has been met. Medicare patients who have a supplemental insurance (recognized by Medicare) must give both
cards to the front office so we may bill them for the remaining 20% of Medicare approved charges. Otherwise, the patient is
responsible for the 20% not covered by Medicare.
Workers Compensation: We will verify your workers’ Compensation claim and obtain authorization for treatment with
your employer’s insurance company. Only authorized visits will be scheduled. If your claim is delayed or denied, we will
notify you immediately. It is important that you provide us with updated referrals to continue therapy.
Auto Claims: We require that the insured have Med-Pay available for this claim. We will verify eligibility with your auto
insurance. In the event that your auto Med-Pay is exhausted, you will be financially responsible for all services rendered.
We do not bill 3rd party insurance.
Self Pay: We do offer non-insurance/out of pocket plans. If you wish to bill your own insurance, we require payment in full
at time of service. We will provide you with a statement of charges and a copy of the physician’s referral .
Other: NSF-Check Return: A $25 fee will be charged if a check is returned for insufficient funds or a closed account.
Note: As a courtesy, INDIVIDUALIZED PHYSICAL THERAPY will bill your insurance company for you. If you have no
insurance coverage, a large deductible or financial hardship, please speak to the frnt office personnel regarding a payment
plan.
Authorization to pay / financial agreement:
I hereby authorize my insurance benefits to be paid directly to INDIVIDUALIZED PHYSICAL THERAPY for services I
receive. I expressly guarantee payment of any charges left unpaid in whole or in part or determined to not be medically
necessary by the insurance company. In the event of default, I agree to pay all costs of collections, and reasonable
attorney’s fees. I also authorize INDIVIDUALIZED PHYSICAL THERAPY to release any information to process this claim
and secure the payment of benefits, insurance company, attorneys, assignees and or beneficiaries. If further agree that a
photocopy of this agreement shall be valid as the original.
I acknowledge that I have read a copy of INDIVIDUALIZED PHYSICAL THERAPY’s Insurance and
financial information and Privacy Practices. I further acknowledge that a copy of the current
notice is posted in the reception area and that I will be offered a copy of any amended Notice Of
Privacy Practices at my next appointment.
Patient's Printed Name
Patient’s signature
Date
3|Page
CONSENT TO TREAT
I give permission for Tracy Halmos, MPT, ATC, CSCS, to administer physical therapy treatment including,
manual therapy, therapeutic exercise, and modalities. I understand that physical therapy entails the
movement and treatment of muscles and joints. For that reason, I understand that on occasion, I may
experience increased symptom irritability subsequent to my treatment sessions.
□ Check & Initial
NO SHOWS/CANCELLATIONS
Please notify us within 24 hours if you need to change or cancel your scheduled appointment. If you fail to
do so, you will be subject to having ALL scheduled appointments cancelled.
I understand that if I do not give sufficient notice of cancellation, (as stated above) all scheduled
appointments will be cancelled. I also understand that I may have to wait several weeks to get back in if the
schedule is full.
□ Check & Initial
STATEMENT OF RESPONSIBILITY
IF YOU HAVE HEALTH INSURANCE OF ANY KIND, PLEASE READ OUR POLICY:
We will do everything we can to help you obtain reimbursement from your insurance carrier, however, the
basic responsibility is yours.
INSURANCE:
As a courtesy to you, we will send claims to your insurance company. However, we cannot accept the
responsibility for negotiating claims with insurance companies or other parties. Your are responsible for
payment for services rendered within a reasonable time – REGARDLESS OF THE STATUS OF YOUR
CLAIM. In circumstances where a claim is pending, or when treatment is needed for an extended period of
time, it is recommended that a payment plan be initiated. We will gladly assist in designing a plan to meet
your needs.
REDUCTION OR REJECTION OF YOUR CLAIM:
Your insurance policy is a contract between you and your insurance company. It is important that you
understand its provisions. We cannot guarantee payment of your claim. Reduction or rejection of your claim
by your insurance company does not relieve the financial obligation you have incurred.
I HAVE READ AND UNDERSTAND THE ABOVE STATEMENTS.
Signature:
Date:
4|Page
NOTICE OF PRIVACY PRACTICES SUMMARY
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Uses And Disclosures Of Health Information
We use health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate
the quality of care that you receive.
We may use or disclose identifiable health information about you without yoru authorization for several other reasons. Subject to
certain requirements, we may give out health information without your authorization for public health purposes, for auditing
purposes, for research studies and for emergencies. We provide information when otherwise required by law, such as for law
enforcement in specific circumstances. In any other situation, we will ask for your written authorization before using or
disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can
later revoke that authorization to stop any future uses and disclosures.
We may change our policies at any time. Before we make a significant change in our policies, we will change our notice and post
the new notice in the waiting area and in each examination room. You can also request a copy of our notice at any time. For
more information about our privacy practices, contact our office.
Your Rights
Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information
belongs to you. You have the right to:
•
Request a restriction on certain uses and disclosures of your info. As provided by 45 CFR 164.522
•
Obtain a paper copy of the privacy practice up request
•
Inspect and obtain a coy of your health record as provided for in 45 CFR 164.524
•
Amend your health record as provided in 45 CFR 164.528
•
Request communications of your health information by alternative means or at alternative locations
•
Revoke your authorization to use or disclose health information except to the extent that action has already been taken.
Following is a statement of your rights with respect to your protected health information and a brief description of how you may
exercise these rights.
Complaints
If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your
records, you may contact our office. You also may send a written complaint to the U.S. Department of Health and Human
Services. Our office can provide you with the appropriate address upon request.
Our Legal Duty
We are required by law to protect the privacy of your information, provide this notice about our information practices, and follow
the information practices that are described in this notice.
If you have any questions or complaints, please contact our office by phone or in writing at 17705 Hale Ave Bldg H-6, Morgan
Hill, CA 95037 or call (408)788-6800.
I acknowledge that I have reviewed the notice of privacy practices which provide a description of the information uses and
disclosures. I understand that I have the right to request restrictions as to how my health information may be used or disclosed
and that the organization is not required to agree to the restrictions I request.
Signature of Patient or Legal Representative
Date
5|Page
**STOP HERE**
(PLEASE SEE ADDRESS BELOW)
The NEXT FOUR pages are for MEDICARE patients
only.
If you are NOT on MEDICARE, please check the
previous FOUR pages to be sure you have signed,
check marked, and initialed where indicated.
If you ARE on MEDICARE, please continue and sign
all pages where (if) indicated.
PLEASE NOTE ADDRESS CHANGE:
Individualized Physical Therapy
17705 Hale Ave Bldg H-6
Morgan Hill, CA. 95037
WE ARE NO LONGER AT 18181 BUTTERFIELD
6|Page
Self-Assessment of Fall Risk
Do you think you would trip or fall under the following circumstances, use the key below to determine
your answer:
100% confident you would NOT trip or fall
50% confident you would NOT trip or fall
0% confidence- You would definitely trip or fall
Please Circle One:
Walking during the daytime on hardwood floor with shoes on:
0%, 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100%
Walking in the dark or with your eyes closed on hardwood floors without shoes:
0%, 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100%
Walking on uneven surfaces like grass, gravel or uneven pavement:
0%, 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100%
Stepping up a curb without holding on to another person or using an assistive device.
0%, 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100%
Sitting down to a low chair (toilet) without using a grab bar:
0%, 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100%
Picking something off the ground:
0%, 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100%
Medicare Home Health Questionnaire
Medicare patients, If you have been enrolled in any Home Health Care Services, you MUST be
discharged from ALL services prior to obtaining outpatient services. Prior to receiving care, it is
the policy of INDIVIDUALIZED PHYSICAL THERAPY to receive a copy of the discharge
paperwork from the Home Health Agency stating you have been discharged from all services to
include, (nursing, physical therapy, and occupational therapy).
Signature:
Date:
Signature:
Date:
Name of Home Health Program:
Phone Number:
Discharge Date:
7|Page
BACK INDEX
PATIENT NAME
DATE
This questionnaire will give your provider information about how your back condition affects your everyday life. Please answer
every section by marking the one statement that applies to you. If two or more statements in one section apply, please mark the
one statement that most closely describes your problem.
Pain Intensity
0.
1.
2.
3.
4.
5.
The pain comes and goes and is very mild
The pain is mild and does not vary much
The pain comes and goes and is moderate
The pain comes and goes and does not vary much
The pain comes and goes and is very sever
The pain is very severe and does not vary much.
Sleeping
0.
1.
2.
3.
4.
5.
I get no pain in bed
I get pain in bed but it does not prevent sleep
Because of pain my normal sleep is reduced by 25%
Because of pain my normal sleep is reduced by 50%
Because of pain my normal sleep is reduced by 75%
Pain prevents me from sleeping at all
I can sit in any chair as long as I like
I can only sit in my favorite chair as long as I like
Pain prevents me from sitting more than 1 hour
Pain prevents me from sitting more than ½ hour
Pain prevents me from sitting more than 10 mins
I avoid sitting because it increases pain immediately
Standing
0.
1.
2.
3.
4.
5.
I can stand as long as I want without pain
I have some pain while standing but it does not increase
I cannot stand for longer than 1 hour without increasing pain
I cannot stand for longer than ½ hour without increasing pain
I cannot stand for longer than 10 mins without increasing pain
I avoid standing because it increases pain immediately
Walking
0.
1.
2.
3.
4.
5.
I have no pain while walking
I have some pain while walking but it doesn’t increase with
distance
I cannot walk more than 1 mile w/o increasing pain
I cannot walk more than ½ mile w/o increasing pain
I cannot walk more than ¼ mile w/o increasing pain
I cannot walk at all w/o increasing pain
Personal Care
0.
1.
2.
3.
4.
0.
1.
2.
3.
4.
I can lift heavy weights without extra painI can lift heavy
weights but it causes extra pain
Pain prevents me from lifting heavy weights off the floor
Pain prevents me from lifting heavy weights off the floor but I
can manage if they are conveniently positioned (e.g. on a table)
Pain prevents me from lifting heavy weights off the floor but I
can manage light to medium weights if they are conveniently
positioned
I can only lift very light weights
Traveling
0.
1.
Sitting
0.
1.
2.
3.
4.
5.
Lifting
2.
3.
4.
5.
I get no pain while traveling
I get some pain while traveling but none of my usual forms of travel
make it worse
I get extra pain while traveling but it does not cause me to seek
alternate forms of travel
I get extra pain while traveling which causes me to see alternate
travel
Pain restricts all forms of travel except that done while lying down
Pain restricts all forms of travel
Social Life
0.
1.
2.
3.
4.
5.
My social life is normal and gives me no extra pain
My social life is normal but increases the degree of pain
Pain has no significant effect on my social life apart from limiting my
more energetic interests (e.g., dancing, etc)
Pain has restricted my social life and I do not go out very often
Pain has restricted my social life to my home
I have hardly any social life because of the pain
Changing Degree Of Pain
0.
1.
2.
3.
4.
My pain is rapidly getting better
My pain fluctuates but overall is definitely getting better
My pain seems to be getting better but improvement is slow
My pain is neither getting better or worse
My pain is gradually worsening
5.
My pain is rapidly worsening
I do not have to change my way of washing or dressing in
order to avoid pain
I do not normally change my way of washing or dressing even
though it causes some pain
Washing and dressing increases the pain but I manage to
change my way of doing it
Because of the pain I am unable to do it all on my own
Because of the pain I am unable to do any of it on my own
without help
Index Score = [Sum of all statements selected]
_Assessment:
_TOTAL:______________________________________________
_____________________________________________________
_____________________________________________________
8|Page
Neck Index
PATIENT NAME
This questionnaire will give your provider information about how your back condition affects your everyday life. Please answer
every section by marking the one statement that applies to you. If two or more statements in one section apply, please mark the
one statement that most closely describes your problem.
Pain Intensity
0.
1.
2.
3.
4.
5.
I have no pain at the moment.
The pain is very mild at the moment.
The pain comes and goes and is moderate
The pain is fairly severe at the moment.
The pain comes and goes and is very sever
The pain is is the worst imaginable at the moment..
Sleeping
0.
1.
2.
3.
4.
5.
I have no trouble sleeping.
My sleep is slightly disturbed (less than 1 hour sleepless)
My sleep is mildly disturbed (1-2 hours sleepless).
My sleep is moderately disturbed (2-3 hours sleepless).
My sleep is greatly disturbed (3-5 hours sleepless).
My sleep is completely disturbed (5-7 hours sleepless).
Reading
0.
1.
2.
3.
4.
5.
I can read as much as I want with no neck pain.
I can read as much as I want with slight neck pain.
I can read as much as I want with moderate neck pain.
I cannot read as much because of moderate neck pain.
I can hardly read at all because of sever neck pain.
I cannot read at all because of neck pain.
Concentration
0.
1.
2.
3.
4.
5.
I can concentrate fully when I want with no difficulty.
I can concentrate fully when I want with slight difficulty.
I have a fair degree of difficulty concentrating when I want.
I have a lot of difficulty concentrating when I want.
I have a great deal of difficulty concentrating when I want.
I cannot concentrate at all.
Lifting
0.
1.
2.
3.
4.
5.
I can lift heavy weights without extra pain.
I can lift heavy weights but it causes extra pain.
Pain prevents me from lifting heavy weights off the floor, but I
can manage if they are conveniently positioned (e.g. on a
table)
Pain prevents me from lifting heavy weights off the floor, but I
can manage light to medium if they are conveniently
positioned.
I can only lift very light weights
I cannot lift or carry anything at all.
Driving
0.
1.
2.
3.
4.
5.
I can drive my car without any neck pain.
I can drive my car as long as I want with slight neck pain.
I can drive my car as long as I want with moderate neck pain.
I cannot drive my car as long as I want because of moderate neck
pain.
I can hardly drive at all because of severe neck pain.
I cannot drive my car at all because of neck pain.
Recreation
0.
1.
2.
3.
4.
5.
I am able to engage in all my recreation activities without neck
pain.
I am able to engage in all my usual recreation activity with some
neck pain.
I am able to engage in most but not all my usual recreation
activities because of neck pain.
I am only able to engage in a few of my usual recreation activities
because of neck pain.
I can hardly do any recreation activities because of neck pain.
I cannot do any recreation activities at all.
Headaches
Work
0.
1.
2.
3.
4.
5.
I can do as much work as I want.
I can only do my usual work but no more.
I can only do most of my usual work but no more.
I cannot do my usual work.
I can hardly do any work at all.
I cannot do any work at all.
0.
1.
2.
3.
4.
5.
I have no headache at all.
I have slight headaches which come infrequently.
I have moderate headache which come infrequently.
I have moderate headaches which come frequently.
I have severe headaches which come frequently.
I have headaches almost all the time.
Personal Care
0.
1.
2.
3.
4.
5.
I can look after myself normally without causing extra pain.
I can look after myself normally but it causes extra pain.
It is painful to look after myself and I am slow and careful.
I need some help but I manage most of my personal care.
I need help every day in most aspects of self-care.
I do not get dressed, I wash with difficulty and stay in bed.
Index Score = [Sum of all statements selected]
_Assessment:
_TOTAL:_____________________________________________
____________________________________________________
____________________________________________________
9|Page
Medicare has asked us to educate patients on their BMI
Your BMI. What does it mean. and what can you do?
BMI Stands for Body Mass Index. ll is a number calculated from your height and weight. It is widely used as a
health screening tool and is used to estimate body fat. but it is not a direct measure of body fat. (Sec chart on
opposite page)
What is your height
What is your current weight
What do the numbers mean?
< 18.5 = Underweight
I8.5-24.9 - Normal Weight
25.0-29.9 - Overweight
> 30.0 = Obesity
Why is it important to know?
Being overweight and obese puts an individual at a higher risk for diseases and poor health conditions. such as,
•
Osteoarthritis
•
Poor wound healing
•
High blood pressure
•
High cholesterol and triglycerides
•
Type 2 diabetes
•
Coronary heart disease
•
Stroke
What can you do?
Physical Activity.
•
Burning more calories than you lake in results in weight loss
•
Expend more calories by increasing your physical activity
•
150 min./week of moderate intensity exercise is recommended for improving health
•
200-300 min./week of moderate intensity exercise is recommended for long-tcrn1 weight loss
•
Talk to your doctor before starting an exercise program
Healthy Eating
•
Eat more fresh fruits and veggies. who grains. fat-free or low fat milk products
•
Eat more lean meats. poultry. fish. eggs. beans. and nuts
•
Eat foods that are low in Cholesterol. saturated fat. trans fat. salt. and sugar
•
Eat smaller portions
•
Talk to your doctor before starting
• a diet
10 | P a g e
Normal
BMI
19 20 21
22
Overweight
23
24
25
26
27
28
Obese
29
30
31 32
Extreme Obesity
33 34 35
36
37 38
39 40
41
42
43
44 45
46
47
48
49
50
51
52
53
54
Height
(inches)
Body Weight (pounds)
56
91
96 100 105 110 115 119 124 129 134 138 143 146 153 156 162 167 172 177 181 186 191 196 201 205 210 215 220 224 229 234 239 244 248 253 258
59
94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173 178 183 188 193 198 203 208 212 217 222 227 232 237 242 247 252 257 262 267
60
97 102 107 112 116 123 128 133 136 143 146 153 156 163 166 174 179 164 169 194 199 204 209 215 220 225 230 235 240 245 250 255 261 266 271 276
61
100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185 190 195 201 206 211 217 222 227 232 238 243 248 254 259 264 269 275 280 285
62
104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191 196 202 207 213 218 224 229 235 240 246 251 256 262 267 273 278 284 289 295
63
107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197 203 208 214 220 225 231 237 242 248 254 259 265 270 278 282 287 293 299 304
64
110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204 209 215 221 227 232 238 244 250 256 262 267 273 279 285 291 296 302 308 314
65
114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210 216 222 228 234 240 246 252 258 264 270 276 282 266 294 300 306 312 318 324
66
118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216 223 229 235 241 247 253 260 266 272 276 284 291 297 303 309 315 322 328 334
67
121 127 134 140 146 153 159 166 172 176 165 191 196 204 211 217 223 230 236 242 249 255 261 266 274 280 267 293 299 306 312 319 325 331 338 344
68
125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230 236 243 249 256 262 269 276 282 289 295 302 308 315 322 328 335 341 348 354
69
128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236 243 250 257 263 270 277 284 291 297 304 311 318 324 331 336 345 351 358 365
70
132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243 250 257 264 271 278 285 292 299 306 313 320 327 334 341 348 355 362 369 376
71
136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250 257 265 272 279 286 293 301 308 315 322 329 338 343 351 358 365 372 379 386
72
140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258 265 272 279 287 294 302 309 316 324 331 338 346 353 361 368 375 383 390 397
73
144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265 272 280 266 295 302 310 316 325 333 340 348 355 363 371 378 386 393 401 408
74
148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272 280 287 295 303 311 319 326 334 342 350 358 365 373 381 389 396 404 412 420
75
152 160 166 176 184 192 200 208 216 224 232 240 248 256 264 272 279 287 295 303 311 319 327 335 343 351 359 367 375 383 391 399 407 415 423 431
76
156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287 295 304 312 320 328 336 344 353 361 369 377 385 394 402 410 418 426 435 443
TOTAL SCORE
11 | P a g e