Patient Form

Last Name *

First Name *

Middle Initial

Address *

City *

State *

Zip Code *

Date of Injury/Onset

Today's Date

Date of Birth

Age

Sex

Male

Female

Marital Status

Single

Married

Divorced

Widowed

Home Phone

Work Phone

Cell Phone *

Email Address *

Injury Area

Accident Related

Yes

No

Accident

Auto

Work

Other

Nature of Accident

Responsible Party

Address

City

Phone Number

Relationship to Responsible Party

Employer

Address

Occupation

City

State

Zip Code

Contact at Employer

Referring Physician

Phone Number

Primary Insurance

Insured Name

Group Number

ID Number

Address

City

Insured Employer

State

Zip Code

Phone

Relationship to Insured

Insured Date of Birth

Insured Sex

Yes

No

Second Insurance

Insured Name

Group Number

ID Number

Address

City

Insured Employer

State

Zip Code

Phone

Relationship to Insured

Insured Date of Birth

Insured Sex

Yes

No

Emergency Contact

Daytime Phone Number

Are you receiving or have you received home health services?

Yes

No

Are you receiving or have you received other therapy services?

Yes

No

CONSENT TO TREATMENT: I consent to rehabilitation and related services at Excel Spine & Sports Rehabilitation. In so doing, I understand, acknowledge and affirm that such rehabilitation and related services may involve bodily contact, touching and/or direct contact of sensitive nature.

TREATMENT OF MINORS: I, as a parent/guardian of a minor receiving treatment hereunder, do hereby agree and understand that I have been advised to remain on the premises during any such treatment, and waive any claim I may have resulting from failure to do so.

LIABILITY: I know and agree that Excel Spine & Sports Rehab is not responsible for loss or damage to personal valuables.

WAIVER AND RELEASE: I hereby release, discharge and acquit Excel Spine & Sports Rehab, it's representatives, affiliates, employees, or assigns, of and from any and all liability, claim, demand, damage, cause of action, or loss of any kind arising out of or resulting from my refusal to accept, receive or allow emergency and or medical services, including but not limited to ambulance service Emergency Medical Technician, physician or urgent care services.

AUTHORIZATION OF PAYMENT: I hereby assign all benefits directly to and also authorize release of any medical records necessary to facilitate my treatment to process medical claims and as otherwise permitted or required in the Notice of Privacy Practices. I understand fully that in the event my insurance company or financially responsible party does not pay for the service I receive, I will be financially responsible for payment.

NOTICE OF PRIVACY: I acknowledge receipt of Notice of Privacy Practices.

I certify that all of the information provided herein is true and correct.

Patient/Guardian Name *

Witness Name *

This form constitutes proprietary information and cannot be used, reproduced or duplicated, in whole or in part, absent written consent of Excel Spine & Sports Rehab. This form must be completed in its entirety and must be provided to Excel Spine & Sports Rehab prior to initiation of therapy services.

Patient Name

Today's Date

Referring Physician's Name

Date of Injury or Onset

Primary Care Physician's Name

Are you presently working?

Yes

No

Cause of Injury or Onset

Date of Next MD Appt

Do you currently have any flu type symptoms?

Yes

No

What Symptoms?

Do you have any open cuts, lesions or wounds?

Yes

No

Where?

Have you fallen in the past year?

Yes

No

How many times?

IF YES TO FALLING, DID YOU SUSTAIN AN INJURY AS RESULT OF THE FALL?

Yes

No

What is your reason for attending therapy?

Because of your problem, what specific activities are you having difficulty with?

What are your personal goals or outcomes you hope to achieve from therapy?

Describe your general health

Excellent

Good

Fair

Poor

Do you use tobacco?

Yes

No

How much?

Wear glasses/contacts?

Yes

No

Have you recently been hospitalized or had surgery?

Yes

No

When?

Why?

Have you had prior physical/occupational therapy for this condition?

Yes

No

What has done? / What were the result?

Have you had prior physical or occupational therapy this calendar year?

Yes

No

Was it received at

Hospital

Out Patient Center

Home Health

For how long?

Current Medications

Medication

Reaction

Other

Reaction

ARE YOU ALLERGIC TO LATEX?

Yes

No

Reaction

Are you Allergic to Dexamethasone?

Yes

No

Reaction

Do you currently have or have a history of any of the following conditions?

ANEMIA	ARTHRITIS	CANCER	CARDIOVASCULAR PROBLEMS
HOLTER MONITOR	PACEMAKER	HIGH BLOOD PRESSURE (controlled)	HIGH BLOOD PRESSURE (uncontrolled)
LOW BLOOD PRESSURE	CURRENTLY PREGNANT	DIABETES (controlled)	DIABETES (uncontrolled)
DEPRESSION	DIZZINESS/FAINTING	FRACTURES	HEADACHES
HEPATITIS/HIV	KIDNEY PROBLEMS	MRSA (Methicillin Resistant Staphylococcus Aureus)	OSTEOPOROSIS
RESPIRATORY PROBLEMS	COPD (controlled)	COPD (uncontrolled)	Other
SEIZURES (controlled)	SEIZURES (uncontrolled)	THYROID PROBLEMS	BLOOD THINNERS (Anticoagulants)

Explain

Any other medical problems

Patient Name *

Reviewed by*

Date