Name: __________________________________________ SS#____________________________
Mailing address ________________________________ Birth date: ___________________
City___________________________________ State: ______________ Zip: _____________
Email address ___________________________________ cell# ________________________
Home tele: ________________________ Work phone #’s: ____________________________
Employer: ______________________________________________________________________
City: __________________________________ State: ____________ Zip: ______________
Emergency contact: ____________________________Relationship:____________________
Location:______________________________ Phone number: __________________________
Referring Physician: _________________________Phone:____________________________
City/State: _________________________________ Date of Surgery:__________________
Insurance Co: _______________________ We require a photocopy of your current ins. card .
Planholder’s Name______________________________ DOB of Planholder_______________
Date of Injury/Accident:___________ Cause of injury/accident: __________________
Were you injured on the job? Y/N Did you report the injury? Y/N
For Work Comp Patients Only:
Did you file a Workers Compensation Claim? Y/N Claim#_______________________
Work Comp Insurance Name: ______________________Claims Adjustor:________________
Authorization for treatment – I, the undersigned, knowing the patient and/or self is suffering from a condition requiring physical therapy treatment, hereby voluntarily agree to treatment which may be performed on the patient and/or self for this condition by the Physical Therapist and assistants.
Cancellation Policy : All cancellations require 24 hour notice to avoid a $70.00 cancellation fee. This charge is your personal responsibility and will need to be paid at or before your next visit.
Exceptions are always made for illness or emergencies.
Payment Policy and Billing Contract:
Insurance : JJPT will bill your insurance company as a service to you, if given a credit card guarantee.
Payment of patient’s portion is expected in full at each visit. I authorize the release of necessary medical records to obtain insurance payment. Insurance processing problems are the patient’s responsibility. Any outstanding balance over 90 days will be charged to your credit card. Billing secondary insurance is the patient’s responsibility. . I hereby authorize the above insurance company to send direct payment for services to Johnson & Johnson Physical Therapy, Inc.
Credit Card #____________________Exp date_____ Security Code:_____
Private Pay
: Payment at the time of service will entitle you to a time of service discount.
All patients : Payment at the time of service is expected and helps prevent increased treatment fees. Both parties must agree in writing to any exceptions to this contract. Any balance not paid after 120 days will accrue interest @ 18% per year. At six months we will proceed to small claims court with an additional $100 fee. If you are in a lawsuit/lien, payment must be received as above. We charge a $35 fee for NSF checks. One copy of medical records is provided at no charge.
I agree to the above terms for treatment, payment and cancellations
Signed ________________________________________________ Date: ___________________________

Name: ________________________________ Date: ____________ Visit #: ________
The following information lets us know how you are doing TODAY!
We understand that by limiting your responses to how you are today, we may be catching you on a particularly good or bad day
(PLEASE COMPLETE ALL PAGES OF QUESTIONNAIRE).
Draw on the figure below where you feel pain TODAY .
Use X marks to show where you feel numbness, tingling or pins and needles TODAY.
Use O marks to show where you’ve had any symptoms PRIOR TO TODAY.
Circle the number that describes your symptoms TODAY.
( 0 = No Pain or Never there, 10 = Worst Possible or Always There)
NECK/ARM
LOWER BACK/LEG
1.
How bad is your neck/ upper back pain? 1.
How bad is your back pain?
0—1—2—3—4—5—6—7—8—9—10
2.
How frequent is your neck/upper back pain?
0—1—2—3—4—5—6—7—8—9—10
3.
How bad is your arm pain?
0—1—2—3—4—5—6—7—8—9—10
4.
How frequent is your arm pain?
0—1—2—3—4—5—6—7—8—9—10
5.
How bad is your numbness/tingling ?
0—1—2—3—4—5—6—7—8—9—10
6.
How frequent is your numbness/tingling ?
0—1—2—3—4—5—6—7—8—9—10
0—1—2—3—4—5—6—7—8—9—10
2.
How frequent is your back pain?
0—1—2—3—4—5—6—7—8—9—10
3.
How bad is you leg pain?
0—1—2—3—4—5—6—7—8—9—10
4.
How frequent is your leg pain?
0—1—2—3—4—5—6—7—8—9—10
5.
How bad is your numbness/tingling ?
0—1—2—3—4—5—6—7—8—9—10
6.
How frequent is your numbness /tingling ?
0—1—2—3—4—5—6—7—8—9—10

Indicate how you are doing by CIRCLING the number that best describes your ability TODAY . We understand that by limiting your responses to how you are doing today, we may be catching you on a particularly good or bad day.
1.
(How long can you sit prior to pain? _______ min.) completely 0------1------2------3------4------5------6------7------8------9------10 completely able to do Half Able unable to do
(How long can you stand prior to pain? ______ min.) completely 0------1------2------3------4------5------6------7------8------9------10 completely able to do Half Able unable to do
(How long can you walk prior to pain? ______ min.) completely 0------1------2------3------4------5------6------7------8------9------10 completely able to do Half Able unable to do
(How often do you wake due to pain? ______ ) completely 0------1------2------3------4------5------6------7------8------9------10 completely able to do Half Able unable to do
completely 0------1------2------3------4------5------6------7------8------9------10 completely able to do Half Able unable to do
completely 0------1------2------3------4------5------6------7------8------9------10 completely able to do Half Able unable to do
7.
(Please Specify: _________________________________). completely 0------1------2------3------4------5------6------7------8------9------10 completely able to do Half Able unable to do
completely 0------1------2------3------4------5------6------7------8------9------10 completely able to do Half Able unable to do
completely 0------1------2------3------4------5------6------7------8------9------10 completely able to do Half Able unable to do
completely 0------1------2------3------4------5------6------7------8------9------10 completely

able to do Half Able unable to do
11.
Is there anything else that increases your pain? ___________________________
12.
When and what do you think caused your pain? Why? ____________________
_________________________________________________________________
13.
Since its initiation, has the pain changed?
_______________________________
14.
Have your symptoms: ( )become worse ( )become better ( )remained the same?
15.
What eases your symptoms? __________________________________________
16.
Are you taking any medications? ( ) Yes ( ) No
If yes, what and how much? __________________________________________
17. What are your goals of physical therapy? ______________________________
Have you ever had any of the following? If yes, please briefly note date and specifics:
18. Surgeries? ( )Yes ( ) No __________________________________________
19. History of falls or near falls? ( ) Yes ( ) No _____________________________
20. Are you pregnant? (weeks) ( ) Yes ( ) No _____________________________
21. Other problems that have been diagnosed by a physician? ( )Yes ( )No
_________________________________________________________________
22.
Are you currently under the care of a physician, psychiatrist or other health care professional other than the one who prescribed your physical therapy?
( ) Yes ( ) No If yes, who? __________________________________________

REVIEW OF SYSTEMS Please mark the appropriate ‘NO’ lines, or provide details
NO
___ General (e.g. fever or chills, poor general health, unexplained
DETAILS weight loss, fatigue, unexplained sweating) _________________
___ Skin (e.g. rashes, new skin lesions, or a change in moles) _________________
___ Eyes (e.g. blurred vision, or change in visual acuity) _________________
___ Ears (e.g. ear pain, or difficulty hearing) _________________
___ Nose (e.g. nasal congestion, discharge, or bleeding) _________________
___ Mouth/Throat (e.g. sore throat or difficulty swallowing) _________________
___ Respiratory (e.g. shortness of breath, cough, wheezing) _________________
___ Cardiovascular (e.g. high/low blood pressure, palpitations) _________________
___ Gastrointestinal (e.g. nausea, vomiting, diarrhea, constipation, abdominal pain, discolored stools)
___ Genitourinary (e.g. problems initiating or controlling my bladder, or have problems with urinary frequency)
___ Endocrine (e.g. heat or cold intolerance, weight loss or gain, increasing thirst)
___ Hemato-Immunologic (e.g. bruise easily, bleeding)
___ Psychiatric (e.g. depression, anxiety, suicidal thoughts or attempts)
I verify the above information is complete and accurate.
_____________________________________________
Patient or Guardian
_________________
_________________
_________________
_________________
_________________
_________________
Date

Notice of Johnson & Johnson Physical Therapy
’s Privacy Practices
Our practice is dedicated to protecting the privacy of your medical records. In conducting our business, we will create records regarding you and the treatment we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We are also required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time.
I hereby acknowledge that I was given the opportunity to review the Notice of Privacy
Practice. Please notify the staff if you would like this information.
________________________________ ______________________
Name Date
Parent or Legal Guardian of Minor or Incapacitated Person
For office use only:
____________________ was offered the opportunity to view the Provider’s Privacy Notice on this date. A good faith effort has been made to obtain a written acknowledgement of the patient’s receipt of the Privacy Notice. However acknowledgement has not been obtained in writing because:
_____ Patient refused to sign the Privacy Notice Acknowledgement.
_____ Other reason (Describe below):
_______________________________ ___________________________
Employee Signature Date

JOHNSON & JOHNSON PHYSICAL THERAPY
970-879-4558
PLEASE TAKE THIS PAGE HOME WITH YOU
This is a list of actions that patients can take to help them assist in their recovery process. If something listed here increases your symptoms or raises questions, please stop the activity until you consult with your therapist or M.D. These tips are provided to help you remember certain concepts discussed during our treatment time.
1.
Eliminate or decrease the frequency of activities which cause pain, which just perpetrates the inflammatory and degenerative process. Ask your therapist to provide you with different strategies to perform those activities.
2.
If you get a delayed onset of pain, play Sherlock Holmes and discover what activity you are performing that causes your pain. Ask your PT to provide you with different movement or postural suggestions to help decrease the irritation.
3.
With acute or recent injuries always apply ice, no more than 15 minutes at a time, once every hour.
4.
Ice is also helpful with chronic or inflammatory pain, especially pain which comes on after an activity.
5.
Heat helps with stiffness and achiness, but should not be used with acute symptoms as it causes swelling.
6.
If you do not get increased symptoms with walking, you should take therapeutic walks. The ideal is twice a day to tolerance or 15 minutes. It is OK if you want to walk longer as long as it does not increase your symptoms.
7.
To improve you must do your exercise program as prescribed by your therapist and utilize pain free and proper body mechanics. This is your part of the team approach to resolving your pain.
8.
Many patients have found that drinking more water has helped them reduce the soreness from treatment and to assist their problem. Drink up to eight tall glasses of water a day, especially on treatment days.
9.
Many M.D.’s recommend taking vitamins during the recovery stages of a physical injury.
Vitamin C, which is important in developing scar tissue, has been recommended to assist the healing process. Some recommend as much as 2-3 grams if it does not cause loose stools.
10.
Become aware if your pain is increased by muscle tension and stress. If you tend to hold the area of pain tightly, begin to train yourself to keep the muscles of the area relaxed. If you find this difficult, bio-feedback can often be helpful in training you to be more relaxed.

MISSION STATEMENT - Johnson and Johnson Physical Therapy is committed to providing specialized care for individuals suffering from acute and chronic pain, complex sports related injuries, and neurological disorders. We offer this care in a supportive and encouraging environment with an emphasis on patient care and directed self-responsibility. Treatment emphasis is on Functional Manual
Therapy, which includes Functional Mobilization, soft tissue and joint mobilization, Back Education and Training, and individualized exercise programs.
The clinic staff is comprised of the following professionals:

Gregory S. Johnson, PT, FFCFMT – Mr. Johnson is a nationally recognized specialist in the area of pain management and functional rehabilitation. Mr. Johnson has been actively involved in the treatment of patients and development of state of the art evaluation and treatment techniques since 1971. His teaching organization, the Institute of Physical Art, offers over 100 seminars nation-wide and trains thousands of physical therapists each year in soft tissue and joint mobilization (Functional Mobilization), movement reeducation, body mechanics, and exercise training. Each year this organization certifies a select group of therapists as Certified
Functional Manual Therapists (CFMT). These therapists have completed extensive training through the Institute of Physical Art and those certified are recognized nationally as some of the countries most accomplished therapists. Annually, a CFMT therapist is selected to participate in an advanced one-year clinical residency program at JJPT. Mr. Johnson was a faculty member in the Master’s/Doctoral programs at the University of St. Augustine and
Chatham College in Pennsylvania. He is currently a faculty member of Touro College,
Bayshore, NY. Through JJPT, Mr. Johnson assists the trainer at Steamboat Springs High
School. Gregg is the father of two young men, Ryan and Tyler.

Vicky Saliba Johnson, PT, FFCFMT - Mrs. Johnson is a nationally recognized specialist in the area of movement reeducation and exercise training. Mrs. Johnson has been actively involved in the treatment of patients, the development of Back Education and Training (BET), and corporate training programs since 1977. She co-owns Johnson and Johnson Physical
Therapy and The Institute of Physical Art with Mr. Johnson. At JJPT, she serves as a consultant for complex patients. At IPA they oversee the development and management of ten separate courses taught over 100 times per year by a faculty of over 50 therapists nation-wide. Mrs.
Johnson was a faculty member in the Masters/ Doctoral programs at the University of St.
Augustine and Chattum College. She is currently a faculty member of Touro College,
Bayshore, NY. Mrs. Johnson has done extensive corporate training for back injury prevention including Seneca Coal Mine and Pacific Gas & Electric Corporation in California.

Brent Yamashita, MPT, CFMT received both his Bachelors of Science and Master’s degrees in Physical Therapy from California State University of Fresno in 1995 and 1997 respectively.
He began his training with the Institute of Physical Art in 2001. He has successfully incorporated the training he has received from the Institute working with orthopedic and neurological patients at a private practice in Fresno, CA. From 2003 to 2005, Brent had the unique opportunity to collaborate with a group of pain management physicians (physiatrists) while serving as the Director for Physical Therapy services in a PT owned practice. It was during this time that Brent’s role as an educator with doctors became a significant part of the outcomes and quality of care that his patient’s received. In 2009 Brent passed the certification in Functional Manual Therapy (CFMT) with distinction and at the top of his class. Accepting the opportunity to practice in Steamboat Springs with some of the best therapists today included transplanting his wife and 3 young daughters. They all enjoy snow shoeing, being outdoors, and life adventures together. Brent has also run marathons and half marathons at average speed, plays floorball, the guitar, and may occasionally ollie on a skateboard or break forth in spontaneous breakdance.


Brian Weber, DPT, CFMT, FAFS graduated Summa Cum Laude from Winona State
University with a Biology degree in 2001. In 2004 he earned his Doctor of Physical Therapy degree from the University of Iowa. Soon after graduating Brian began taking classes with the
Institute of Physical Art. In 2008 he completed a Fellowship through the Gray Institute under the direction of Gary Gray, PT and David Tiberio, PT, PhD. In 2011 Brian completed the
Certification in Functional Manual Therapy (CFMT) with honors. Following this certification
Brian was asked to be a secondary instructor for Back Education and Training for the Institute of Physical Art. Since graduation he has been employed by River Falls Sports Medicine,
Rehabilitation and Wellness Center in River Falls, WI. Over the past 5 years he has also worked part time at a nursing home as the supervising Physical Therapist. Brian was honored to be accepted for the year long fellowship in Steamboat Springs and to be around some of the most talented physical therapists in the country. Brian has been happily married to his wife
Julie for almost 7 years and they enjoy spending time with their dog (Moose) and three cats.
Interests outside of physical therapy include spending time with family and friends, refereeing basketball, being outdoors and when there is snow having his wife teach him how to cross country ski.

Steve Warfel DPT, MTC, CFMT graduated from Penn State University with a B.S in
Exercise Physiology in December of 1999. He completed his Masters and Doctorate degrees in
Physical Therapy at the University of St. Augustine for Health Sciences in 2001 and 2002 respectively, earning high honors and also the Manual Therapy Certification (MTC). During his time in St. Augustine, he was introduced to the IPA when Vicky Johnson taught PNF I, inspiring him to continue taking IPA courses. In 2010 Steve completed the Certification in
Functional Manual Therapy (CFMT) with honors. Since certification, Steve has been very active with the IPA, lab assisting courses in Denver, and working in Steamboat whenever there was opportunity. Steve was honored to be accepted to the fellowship program and have such a unique opportunity to study with talented therapists and hone his skills. Steve moved to
Steamboat with his fiancé, Larissa Wilson, and their 18 year old cat Scruffy. He is an avid outdoorsman and enjoys snowboarding, hiking, nordic skiing, and mountain biking. He has raced mountain bikes at CAT 1 and 2 levels for six years for a team out of Golden, Feedback
Sports, and intends to compete in Steamboat also.
Front office staff –Nora Matteo, Jill Miller & Page Stockdale
The therapist’s role at JJPT is to identify the underlying dysfunction perpetuating the presenting clinical symptoms. The therapist then works together with the patient to develop and implement a personalized treatment program, which includes state of the art manual therapy, body mechanics training, and exercise. The therapists at JJPT function as a team and they will often consult with one another on complex patients to ensure the highest level of care. Because of the diverse specialties offered by each therapist, patients are often scheduled with more than one therapist to receive a complete well-rounded approach to the treatment of their problems. While patients can be seen without a physician’s referral, it is the preference of the staff at JJPT that all patients are treated in conjunction with a referring physician.
The patient’s role at JJPT is to commit 100% to the program. This involves doing your exercises, applying daily what you are taught about body mechanics, and providing accurate feedback to your therapist about your progress. In addition, it is the patient’s responsibility to inform the therapist one week prior to a follow-up physician’s visit so reports can be provided. Also, it is your responsibility to make sure your physician prescription is current. Remember your rehabilitation is a team effort!
The front office staff is available to assist you in scheduling appointments. They will bill your insurance company as a courtesy to you, our patient. Ultimate financial responsibility is yours.
It is our pleasure to make you feel comfortable in a truly healing and caring environment.
Thank you, for making us a part of your rehabilitation team .
The staff and professionals of JJPT