ABSOLUTE PT INTAKE

Name

Email Address

example@example.com

DOB

Date

Home Phone

Format: (000) 000-0000.

Cell Phone

Format: (000) 000-0000.

Address

Home Address

Street Address Line 2

CityState

Zip

GoodFairPoor

YesNo

If yes, please list each one:

Rows	Yes	No
Do you smoke or use tobacco in any other form?
For Women: Are you taking birth control pills?
Are you pregnant?
Are you nursing?

Click here

If pregnant, how many weeks?

(please select option that applies)

Rows	Yes	No
Anemia/Radiation treatment
Artificial Bone/joints/valves
Arthritis
Asthma
Blood Transfusion
Cancer/Chemotherapy
Congenital Heart Defect
Diabetes
Difficulty Breathing
Drug/Alcohol Abuse
Emphysema / Glaucoma
Epilepsy / Seizures / Fainting Spells
Fever Blisters / Herpes
Heart Attack / Stroke
Heart Murmur
Heart Surgery / Pacemaker
Hemophilia/Abnormal bleeding
Hepatitis
High / low Blood Pressure
HIV+/AIDS
Hospitalized for any Reason
Kidney problems
Mitral Valve Prolapse
Psychiatric Problem
Rheumatic / Scarlet Fever
Severe / Frequent Headaches
Shingles
Sickles Cell Disease / Traits
Sinus Problems
Tuberculosis (TB)
Ulcers / Colitis
Venereal Disease

Are you allergic to any of the following?

Rows	Yes	No
Aspirin
Codeine
Penicillin
Erythromycin
Tetracycline
Jewelry / Metals
Latex
Icy Hot balm cream (BenGay/Icy Hot/Mentholatum)

List any other drugs/materials you are allergic to:

Please list any serious medical condition(s) that you ever had:

Understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office any changes in my medical status.

Signature

Date

I have volunteered to participate in a program of health care (possibly including but not limited to Physical therapy, Occupational Therapy or Acupuncture and to retain the services of Absolute Physical Therapy & Rehab Center Inc. and its employees, independent contractors and/or any future employees or independent contractors to receive said services. I intend to assume all risk of injury from my participation. To that end, I acknowledge and agree to all of the following:

1. The treatment may include but is not limited to one or more of the following: evaluation, manual therapy, joint mobilization and manipulation, soft tissue mobilization, therapeutic exercise, neuromuscular re-education, therapeutic activities, and modalities including but not limited to ultrasound, acupuncture needles, electrical stimulation, biofeedback, and hot and cold packs. There are inherent risks involved in any evaluation and treatment program. It is not possible to guarantee or give assurance of a successful result. It is important that you understand and agree to the planned treatment. Physical Therapy is generally safe and helpful. However, medical procedures of any type involve the taking of risks, ranging from minor to serious (including the risk of death). It is important to be aware of the following risks before you receive the treatment you and your health care provider are planning.

2. The possible benefits of this treatment include: decreasing pain, improving cardiovascular fitness, muscle strength, endurance, flexibility, improved body posture, movement and alignment. During treatment there exists a potential for numerous side effects including but not limited to muscle soreness or stiffness; skin tear, blister, numbness, tingling, or other paresthesia; muscle tears; bony fractures; paralysis; abnormal blood pressure, cerebrovascular accidents, fainting, disorders of heartbeat, and instances of heart attack and death. I assume all of the foregoing risks, and accept personal responsibility for any other damages or other injury I might suffer. I am satisfied with my understanding of the more common risks and complications of the evaluation and treatment. In case during treatment and I experience any of these side effects, I understand that I need to inform and notify the therapist BEFORE I leave the clinic premises for the current day.

3. I know I have the right to choose what treatment I do or do not receive in addition to withdrawing from any treatment at any time.

4. I understand that a physician’s examination and approval should be obtained prior to participation in a health care program.

5. I recognize that my participation in the activity covered hereby is conditioned upon my signing and returning this waiver and release. I understand that I may show this INFORMED CONSENT and WAIVER & RELEASE OF LIABILITY to, and consult with, my own independent legal counsel before signing.

6. Absolute Physical Therapy & Rehab Center Inc. and its employees, independent contractors and/or any future employees or independent contractors have not made any representation as to the nature and quality of the facilities or equipment to be used or as to any other matter related to my participation in the foregoing activity. I understand that the “RELEASEES” enumerated above or otherwise owe no duty or obligation to me.

7. I have read and understood this INFORMED CONSENT and WAIVER & RELEASE OF LIABILITY and it accurately sets forth my intentions and I agree to be bound by its provisions.

Print Name:

Date of Birth:

Date

SIGNATURE:

Date:

Date

I acknowledge that I have read and will receive a copy of this summary of Notice of Privacy and can request a copy of the entire Notice of Privacy Practice from the front desk/office. I understand that the Notice of Privacy Practice explains my privacy rights regarding my Protected Health Information as set forth by the Health Insurance Portability and Accountability Act. I am aware of my rights and have provided my signature below to attest to my understanding of my rights under this federal law.

PRINT NAME:

TEL NO.:

Please enter a valid phone number.Format: (000) 000-0000.

SIGNATURE

DATE

Date

This is just a guide but you can change/push the dates and time as long as your prescription for therapy is completed. If at the middle of your prescribed visits you see your doctor and tell you that you are okay and don't need more therapy this means your doctor may not prescribe you additional therapy, but you can still complete the original prescription. Thank You.

1st

2nd

3rd

4th

5th

6th

7th

8th

9th

10th

11th

12th

Patient Name:

DOB:

Date

Please indicate below which way you would like to be reminded:

EMAIL

I_______authorize Absolute Physical Therapy & Rehab Center, Inc. to send AppointmentReminders electronically via Email to the following email address.

PATIENT NAME:

EMAIL ADDRESS:

example@example.com

TEXT MESSAGE

I_______authorize Absolute Physical Therapy & Rehab Center, Inc. to send Appointment Reminders electronically via text message to my mobile phone. I understand that this service is offered free of charge. However, standard text messaging rates from my mobile carrier may apply. Please activate text message reminders for the patient/mobile phone number:

PATIENT NAME:

MOBILE

Format: (000) 000-0000.

MOBILE CARRIER:

VOICE MESSAGE

I_______authorize Absolute Physical Therapy & Rehab Center, Inc. to contact me for Appointment Reminders via voice messaging. If I am unavailable to answer the telephone, I give Absolute Physical Therapy & Rehab Center, Inc. permission to leave a message on my answering machine or with the person answering the telephone.

PATIENT NAME:

TELEPHONE#:

Format: (000) 000-0000.

Patient Signature:

Date

Parent/Legal Guardian Signature:

Date

MEDICAL HISTORY

Informed Consent and Waiver & Release of Liability

PRIVACY PRACTICE NOTICE SUMMARY ACKNOWLEDGEMENT

NEXT PHYSICAL THERAPY APPOINTMENTS

APPOINTMENT REMINDER AUTHORIZATION FORM