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Search for:
Home
About
Our Process
Blog
Meet the Team
Videos
Services
First Time Visits
Health & Fitness
Contact
NEW PATIENT INFORMATION
WHOLE TRACK
2020-03-19T17:02:07+00:00
NEW PATIENT INFORMATION
Step
1
of
5
20%
Date (todays date):
*
MM slash DD slash YYYY
Name:
*
First
Last
Birthdate:
*
MM slash DD slash YYYY
Sex:
*
MALE
FEMALE
Age:
Please enter a number from
0
to
120
.
Email:
*
Enter Email
Confirm Email
Address:
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Mobile Phone:
Work Phone:
Home Phone:
Primary Care Physician Name:
Physician Phone #:
When is the last time you were seen by physician?
IN CASE OF EMERGENCY, CONTACT:
Name:
Relationship:
Phone #:
WHOM MAY WE THANK FOR REFERRING US?
Check one or more below:
*
Website
Facebook
Google
MLO
Other
If Other Please Explain Below::
HIPAA INFORMATION RELEASE AUTHORIZATION
Effective starting as of (Today’s Date):
*
MM slash DD slash YYYY
In accordance with the new HIPAA privacy laws, Free Motion Physical Therapy can no longer discuss any protected health information with any person other than the patient, doctor, insurance company and/or specified person(s). If you would like your information released to your spouse or any other person, you need to sign a records release form. We appreciate your cooperation in helping maintain patient confidentiality.
I (Name)
*
First
Last
hereby authorize Free Motion Physical Therapy to release any information (if necessary), including reminders of appointments, the diagnosis and records of any treatment, examination, or evaluation rendered to the undersigned patient, and all financial records to:
Release to persons listed below (Click + to Add More):
Name
Relationship
HIPAA PRIVACY PRACTICES ACKNOWLEDGEMENT
I acknowledge and understand that Free Motion follows the HIPPAA Privacy Act to keep my info secure and that at any time I can request a copy of the HIPPA Patient Privacy notice.
Signature (sign here)
*
Agreement!
*
Click here to agree to the above terms
By filling in the signature field above and clicking this checkbox I agree to allow this release.
REASON FOR VISIT:
Please be very specific on exactly what you would like to address:
1. Please describe your main reason for visiting us.
*
a. How did this condition start?
*
b.. When did this condition start?
*
c. What treatments have you had for this?
*
d. If so, what were the results?
e. Have you had physical therapy before for this?
*
Yes
No
f. Is your pain constant?
*
Yes
No
g. What increases your pain?
*
h. What decreases your pain?
*
ANOTHER REASON FOR YOUR VISIT
If there is an additional reason for your visit please tell us below.
2. (Any other reason for this visit?)
a. How did this condition start?
b.. When did this condition start?
c. What treatments have you had for this?
d. If so, what were the results?
e. Have you had physical therapy before for this?
Yes
No
f. Is your pain constant?
Yes
No
g. What increases your pain?
h. What decreases your pain?
MEDICAL HISTORY:
Do you have any of the following? Please select “Yes” or “No”
Allergies
*
Yes
No
High Blood Pressure
*
Yes
No
High Cholesterol
*
Yes
No
HIV
*
Yes
No
Epilepsy
*
Yes
No
Asthma
*
Yes
No
Stroke
*
Yes
No
Diabetes
*
Yes
No
Digestive Disorder
*
Yes
No
Dizziness
*
Yes
No
Arthritis
*
Yes
No
Numbness
*
Yes
No
Headaches
*
Yes
No
Hepatitis
*
Yes
No
Cancer
*
Yes
No
If Yes please give details:
Heart problems
*
Yes
No
If Yes please give details:
Clotting disorder
*
Yes
No
If Yes please give details:
Do you smoke?
*
Yes
No
If yes, how many packs a week?
For how many years?
Do you drink alcohol?
*
Yes
No
If yes, how much per week?
For how many years?
Are you pregnant?
Yes
No
Please list any childbirth experiences you have had:
Who is your referring physician?
Who is your primary care physician?
Recreational drug use?
*
Yes
No
If yes please describe:
Do you have any STDs?
*
Yes
No
If yes please describe:
Do you exercise regularly?
*
Yes
No
How often?:
Do you have any metal implants?
*
Yes
No
If yes please describe:
Do you have a cardiac pacemaker?
*
Yes
No
If yes, how long have you had it?
Adverse reactions to any medications?
*
Yes
No
If yes what reaction occurs?:
Please list any medications you are taking:
*
Please list all surgeries, major illnesses and/or injuries and the year of their occurrence:
*
Consent
*
Consent Agreement
I hereby agree to allow Free Motion Physical Therapy to contact me by phone, text, email or direct mail. Absolutely no spam we promise!
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