Patient Information Sheet

DATE: PATIENT#:__________________

PLEASE ANSWER COMPLETELY, PLEASE PRINT LEGIBLY

Patient Name:_______________________________________ Birth Date:____________ Age___________

Address:_____________________________________________Patient Soc. Sec. # _____________________
City: __________________________________State ___________________Zip Code:__________________
Home Phone ______________ Cell Phone ______________ Email _________________________________
Gender: M¨ F¨ Marital Status: ¨ Single ¨ Married ¨ Divorced ¨ Separated ¨ Widowed
Patient Employed by_____________________________________________ Work Phone: _______________
Name of Insured (if other than patient) _________________________________________________________
Insured Social Security #________________________Birth Date:____________
Insured Employed by ___________________________________________ Work Phone _________________

Referring Doctor: Name:___________________________

Insurance Information: Please provide a copy of your insurance card(s).
¨ M EDICARE (PLEASE NOTIFY US IF YOU RECEIVE ANY MEDICARE-BILLED ASSISTANCE IN YOUR HOME
WHILE YOU ARE AN ACTIVE PATIENT WITH US. IF YOU DO, MEDICARE WILL NOT PAY FOR YOUR PHYSICAL
THERAPY TREATMENT.)
¨ GROUP HEALTH INSURANCE
¨ WORKER’S COMPENSATION
¨ AUTO ACCIDENT

Injury/Accident Information
Date of accident or onset of problem ________________
In your own words, how did this injury or accident occur? ___________________________________________
__________________________________________________________________________________________

In Case of Emergency

Name:____________________________________________ Relationship to Patient ____________________

Address :
Home Phone ____________________ Work Phone __________________Cell Phone ____________________

Who can we thank for referring you to our practice? ¨Internet ¨Yellow Pages ¨Friend _____________
¨ Doctor _____________________________ ¨ Other___________________________________________
PLEASE USE OTHER SIDE FOR ADDITIONAL INFORMATION IF NEEDED

Performax
Physical Therapy
 Performax Physical Therapy
PATIENT MEDICAL HISTORY QUESTIONNAIRE
Name___________________________________________________________________ Date______________
1. Right handed ¨ Left handed ¨ 2. Do you smoke? Yes ¨ No ¨
3. Date of accident/Onset of problem__________________ Work ¨ Motor Vehicle Accident ¨ Other ¨
4. How did your injury, accident, or problem occur?________________________________________________
___________________________________________________________________________________________
5. Have you had physical therapy this year? Yes ¨ No ¨ If yes, how many visits?
______________________
6. Are you currently working? Occupation________________________________________
Pre-injury hours per week_____________ Current hours per week_____________
7. Dates of worked missed due to injury _________________________________________________________
8. Has your doctor given you any activity limitations? Yes ¨ No ¨ _________________________________
9. Have you had any similar past injuries or ailments? Yes ¨ No ¨ Date______________________________
Please explain:____________________________________________________________________________
10. Please list ALL SURGERIES with approximate dates:____________________________________________

11. Please list ALL CURRENT MEDICATIONS: _________________________________________________

12. How long can you do the following WITHOUT increased symptoms?
Sit_________________ Stand_________________ Walk_____________
13. Please rate the following by marking a vertical line on each scale below. Use the scale below like a
thermometer. The scale is marked mild (left) to severe (right). Place a mark on each thermometer that best
describes how you feel in relation to the question next to each scale.
Mild Severe
Present STRESS level
Pain - at its WORST
Pain - at its BEST
Pain - at NIGHT
Pain - MOST of the time
14. Using the body diagram below, please indicate the location of any of the sensations listed. Mark the areas
on the drawings with the symbol that best describes the sensations that you feel.
a) +++++ Sharp Pain b) -------- Numbness c) xxxxxx Spreads to these areas

Please complete Page 2

Performax Physical Therapy Patient Medical Questionnaire Page 2
15. Do you have a FAMILY history of:
Yes No Yes No
___ ___ Cancer ___ ___ Diabetes
___ ___ Gout ___ ___ Heart Disease
___ ___ Hemophilia ___ ___ Osteoarthritis
___ ___ Osteoporosis ___ ___ Psoriasis
___ ___ Sickle Cell Anemia Other __________________________________
16. Have you, or do you currently have, any of the following:
Yes No Yes No
___ ___ Frequent/Severe Abdominal Pain ___ ___ Speech/swallowing problems
___ ___ Appetite Change ___ ___ Anemia
___ ___ Arthritis ___ ___ Artificial Joint(s)
___ ___ Asthma ___ ___ Auto Accident (date)____
___ ___ Back Pain ___ ___ Balance/Coordination Issues
___ ___ Bleeding problems/clots ___ ___ Blood Transfusions
___ ___ Bladder Dysfunction (urine retention, increased frequency, overflow incontinence)
___ ___ Cancer ___ ___ Chest Pain/heaviness in chest
___ ___ Diabetes ___ ___ Discolored or painful Feet
___ ___ Dizziness ___ ___ Fall
___ ___ Fainting Spells ___ ___ Fecal Incontinence
___ ___ Fracture/suspected fracture ___ ___ Gout
___ ___ Unusual growths or lumps ___ ___ Frequent/Severe Headaches
___ ___ Heart Condition(s): _____________________________________________________
___ ___ Frequent Heartburn/Indigestion ___ ___ Changes in Hearing
___ ___ Hepatitis ___ ___ Hypoglycemia
___ ___ High Blood Pressure ___ ___ Infection/Immunosupression
___ ___ Hospitalization: ________________________________________________________
___ ___ Swelling/redness in joint w/o injury ___ ___ Mental Lethargy
___ ___ Metal Implants ___ ___ Night Pain
___ ___ Frequent Nausea/Vomiting ___ ___ Numbness
___ ___ Constant/Severe Pain in Lower Legs ___ ___ Palpitations
___ ___ Pacemaker ___ ___ Pneumonia
___ ___ Physical Fatigue ___ ___ Current Pregnancy
___ ___ Psoriasis ___ ___ Restless/Disturbed Sleep
___ ___ Rheumatic Fever ___ ___ Seizures
___ ___ Saddle Anesthesia (loss of sensation in bowel/urinary muscles)
___ ___ Spontaneous Night Fever/Sweats ___ ___ Shortness of Breath
___ ___ Stroke ___ ___ Swelling (w/o injury)
___ ___ Tumors ___ ___ Tuberculosis
___ ___ Vision changes ___ ___ Urinary Tract Infection
___ ___ Weight Gain/Loss ___ ___ Weakness
Other __________________________________________________________________________________
17. Have you ever experienced any reaction to the following:
___ ___ Aspirin ___ ___ Latex
___ ___ Penicillin ___ ___ Steroids
Other __________________________________________________________________________________

Performax
Physical Therapy (Rev 06/09)
Patient Name________________________________________ Date of Birth_____________________

Name of Insured________________________ Soc.Sec. Number of Insured______________________

Authorization to Bill Insurance (Assignment of Benefits)
GENERAL CONSENT FOR PHYSICAL/OCCUPATIONAL THERAPY TREATMENT
RELEASE OF MEDICAL INFORMATION

I hereby instruct and authorize payment of my physical therapy insurance benefits directly to
PERFORMAX Physical Therapy toward the total charges for professional services rendered. This is A
DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS under this policy; this payment is not to
exceed my indebtedness to PERFORMAX Physical Therapy. I have agreed to pay in a current manner
any balance of said professional services, less any insurance payment. If the insurance company issues a
check to me directly for services rendered by PERFORMAX, I agree that I will sign it over to
PERFORMAX immediately. I also authorize the release of information and medical records to any
doctor, insurance company, adjuster, or attorney involved in this case.

I understand that I am responsible for: obtaining proper authorization from my insurance

company, ascertaining that PERFORMAX can participate with my insurance plan, monitoring the number
of approved visits, and obtaining authorization for additional visits. I understand that I am responsible for
all charges regardless of what type of insurance I have. If my insurance coverage changes or terminates
during the course of my treatment it is my responsibility to make sure that PERFORMAX is notified of
any changes and can participate with my new plan, and I have proper authorization. It is my duty to
understand any and all limits on the number of treatments or policy limits on covered procedures. I
understand that if I receive treatment that is not covered under my policy, I am responsible for payment. I
agree to pay any balance I owe to PERFORMAX in a reasonable and timely manner. In the event that
any collection action is pursued to collect any outstanding balances, I agree to pay all costs of collection,
including reasonable attorney fees, interest and court costs.

I am hereby consenting to and requesting physical therapy service from PERFORMAX

physical therapy to be provided by licensed physical therapist, physical therapy students, and assistants or
therapists designees. My evaluation and treatment, may include but not limited to the following:
observation, palpation, joint mobilization, soft tissue mobilization, modalities such as ultrasound,
electrical stimulation and iontophoresis, exercise (land and/or aquatic), education and instruction, and
neuromuscular techniques. I understand that no guarantees have been or can be provided regarding the
success of physical therapy.

In the interest of safety for all concerned, Performax Physical Therapy reserves the right to deny
treatment to any individual under the influence of alcohol or drugs, or for any abusive conduct.

Additional Expenses: I understand that pillows, gym balls, electrodes and other supplies are an
additional cost that is separate from the cost of physical therapy treatment. Further, if I receive
Iontophoresis as a treatment for my ailment, I understand that this procedure requires special electrodes,
medication, and a Medical Doctor’s prescription and is an additional charge beyond the cost of other
physical therapy treatment.

*_____________________________________________________________ Date: ____________

Authorized Signature (Guardian if under 18)

Performax
Physical Therapy
 Cancellation & No-Show Policy
The following is our policy regarding appointment cancellations and no-shows. We take this subject seriously at
Performax as it can make the difference between whether you succeed in your treatment or not. Usually your
referring doctor and or therapist have prescribed a set frequency of treatment. Showing up as scheduled for these
visits is your most important job. Other than that, all you need to do is follow your therapist’s instructions and we
will be able to help you achieve your goals in treatment.

· We require 24 hours notice in the event of a cancellation. It is your responsibility, when you call in, to
have an alternative treatment time in mind that will ensure you receive the total prescribed number of
treatments that week whenever possible. (In some cases, this may not work since some forms of
treatment do not work well if given two sequential days.)

· There is a $25.00 charge for a cancellation without proper notice. This charge will not be covered by
insurance, but will have to be paid by you personally. (If you are here due to a Worker’s Compensation
or Automobile claim, we are required to notify your adjuster/case manager and physician of missed
appointments.)
NOTE: If you are unable to give 24 hours notice due to conditions that you do not have control over,
please notify the clinic as soon as possible and let us know.

· You may need to see a therapist other than the one who normally treats you if you do rearrange your
appointment. All of our therapists are experienced professionals, and they will study your patient chart, so you
will be in good hands. You will return to your original therapist in the next regularly scheduled visit.

· Please understand that your pain will probably increase and decrease as your course of treatment progresses
and before it is finally released. Either condition can seem to be a reason not to come in: (a) you are feeling
worse and think the treatment is not working, or (b) you are feeling better and it is a great day for golf. Neither
of these conditions are a legitimate reasons not to come: (a) if you are in pain come in and get it fixed, (b) if
you are out of pain, now is the time that we can begin doing some real correction of the underlying causes of
your problem and educate you so you won’t re-injure yourself.

When a patient does not show as scheduled, three people are hurt: (1) the patient him or herself because they
do not get the treatment they need as prescribed by the doctor and or physical therapist, (2) the therapist
who now has a space in their schedule since the time was reserved for that patient personally, and (3)
another patient who could have been scheduled for treatment if there had been proper notice.

We ask for your cooperation in this regard and will have you out of pain and back to full function swiftly. We
look forward to working with you.

______________________________________ ________ __________________________ ________

Patient Signature (Guardian, if patient under 18) Date Interviewer Signature Date

Performax
Physical Therapy
 Performax Physical Therapy Performax Front Range Physical Therapy
5920 S. Estes St. #100 8200 E. Belleview Ave., Suite 505E
Littleton, CO 80123 Greenwood Village, CO 80111
Phone 303-932-2500 Phone 303-741-0235
Fax 303-932-2600 Fax 303-741-4882

Receipt of Acceptance of Notice of Privacy Practices

Our Notice of Privacy Practices provides information about how we may use and disclose
protected health information about you. The Notice contains a Patient Rights section describing
your rights under the law. The terms of our Notice may change. If we change our Notice, you
may obtain a revised copy by contacting our office.

By signing this form, you are affirming that you have been made aware that we have a written
Notice of Privacy Practices and you have been given the opportunity to receive a copy of our
Notice.

This Receipt was signed by: ____________________________________________

Printed Name – Patient or Patient Representative

______________________________ ___________
Signature Date

_____________________________________________
Relationship to Patient (if other than Patient)

Witness: _____________________________________________
Printed Name – Practice Representative

______________________________ ___________
Signature Date