Physical Therapy and Wellness Intake Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. – Step 1 of 3PATIENT INFORMATION – To be completed by patient Name *FirstLastLayoutAddressCityStateZipLayoutDate / TimeAgeSS#LayoutHome Phone #Cell Phone #EmailWould you like to receive appointment reminders?YesNoPlease Check One:CallTextLayoutEmployerOccupationEMERGENCY CONTACT – To be completed by patient LayoutNameRelationship to PatientLayoutHome Phone #Cell Phone #INSURANCE INFORMATION – To be completed by patient. (DO NOT FILL IN IF WE HAVE COPY OF CARDS) LayoutPrimary InsuranceSubscribers DOBSecondary InsuranceSubscribers DOBSubscribers NamePatient Relationship to InsuredSubscribers NamePatient Relationship to InsuredAUTO OR WORK INJURY CLAIMS ONLY – To be completed by patient, as needed LayoutAuto Insurance NameAdjustor/Claims ManagerClaim #Workers Comp. CarrierPhone #Accident DateNextMedical and Pain Assessment LayoutPatient Name *Referring PhysicianDate of InjuryToday's DatePrimary Care PhysicianDate of SurgeryAre you currently under any restrictions from your doctor?Chief Complaint (Reason for your visit today)?Approximately when did this pain begin?Please list any additional areas of pain:What caused your current condition?AccidentOveruseSports InjuryUnknownWorkOtherIf other, please specify *Since your pain began, how has it changed?ImprovedWorsenedStayed the SameWhen is your pain at its worst?MorningsDaytimeEveningsMiddle of NightAlways the sameHow often does the pain occur?ConstantChanges in severity but always presentIntermittent (comes and goes) Based on the above pain intensity scale, please rate your pain: LayoutRight Now Selected Value: 0 At Best Selected Value: 0 At Worst Selected Value: 0 PreviousNextPast Medical History LayoutPatient Name *HeightWeightLayoutDo you exercise regularly?YesNoIf yes, how often?Have you seen anyone else for your current condition?Physician/MDChiropractorOrthopedic SurgeonDentistNeurologistOtherIf other, please specify: *Please check any tests or procedures that have been performed for your current condition:X-RaysMRICT ScanBone ScanEMGBlood WorkBone DensityUltrasoundLayoutHave you had a related surgery?Date of SurgeryPast Medical History Have you ever had any of the following conditions and/or symptoms? Check all that apply. LayoutDiabetes -Type IYesNoDiabetes – Type II YesNoHypoglycemiaYesNoHeart DiseaseYesNoHeart AttackYesNoStroke/CVAYesNoPeripheral NeuropathyYesNoOsteoporosisYesNoCancerYesNoAsthma/Breathing DifficultiesYesNoHigh Blood PressureYesNoAllergiesYesNoList All Allergies *Chest Pain/AnginaYesNoPacemakerYesNoBowel/Bladder AbnormalitiesYesNoDizziness/VertigoYesNoSmokerYesNoRecent FallsYesNoMetal ImplantsYesNoFractures YesNoWhere? *Positive For HIV or HepatitisYesNoOther Conditions:Medications:Surgeries:STATEMENT OF FINANCIAL RESPONSIBILITY Cornerstone Physical Therapy and Wellness appreciates the confidence you have shown in choosing us to provide your rehabilitative needs. As a courtesy, we will verify your coverage and bill your insurance carrier on your behalf. However, you are ultimately responsible for any co-payment at the time of service and on receipt of a bill for any deductible/co-insurance as determined by your insurance carrier. Many insurance companies have additional stipulations that may affect your coverage. You are responsible for any amount not covered by your insurer. If your insurance carrier denies any part of your claim, or if you and your physician elect to continue therapy past your approved period, you will be responsible for your account balance in full. I authorize my insurer to pay any benefits directly to Cornerstone Physical Therapy and Wellness. I agree to pay Cornerstone Physical Therapy and Wellness the full amount of all bills incurred by me, and if applicable, any amount due after payment has been made by my insurance carrier. CONSENT OF TREATMENT AND AUTHORIZATION TO RELEASE INFORMATION I hereby authorize Cornerstone Physical Therapy and Wellness to furnish medical care and treatment to me, or the above named patient, considered necessary in diagnosing or treating my/his/her physical condition. I further authorize Cornerstone Physical Therapy and Wellness to release to appropriate agencies, any information acquired in the course of my, or the above named patient’s, examination and treatment necessary to secure payment for services provided. I acknowledge that I have been provided with a Notice of Privacy Practices and that I have read and understand the notice. I further acknowledge that I have the right to request a copy of the notice and one will be provided to me. MISSED APPOINTMENT POLICY We strive to provide our patients with excellent service and quality care. Our commitment to your well-being and health is something that we take very seriously. Each appointment is scheduled one-to-one with your physical therapist or physical therapy assistant. Your attendance is imperative. An appointment card will be provided to you to keep track of your appointments. You are expected to attend all scheduled appointments; however, should you need to cancel, please note that 24-hour notice is required. If you need to cancel your appointment, please call our office to reschedule. If cancellations are not received within 24 hours, or if you do not show for your appointment, you will be charged $35.00 for the missed appointment. We thank you for choosing Cornerstone Physical Therapy and Wellness, and we look forward to working with you and helping you reach your goals. I have read the above policies, and I certify that the information provided is true and accurate to the best of my knowledge. LayoutPatient/Guardian SignatureBy typing your name below, you acknowledge that this entry serves as your electronic signature.DateCustom Captcha * = Submit True One-to-One Physical Therapy Schedule an Appointment
