Patient Information Form
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Patient Information Form
Date of Call/Registration:
Patient Account Number:
Past Patient
Yes
No
Patient Information
verified DL/photo i.d:.
Yes
No
Last Name/Suffix
First Name
Middle Initial
Address:
City
State:
Zip Code:
Home Phone
Other Phone (Cell)
Email Address
Date of Birth
SSN
Sex:
Status:
Divorced
Single
Married
M
F
Widowed
Separated
Unknown
Employer Information
Employer Name:
Employment Status:
None
FT
PT
Stud
Self-Emp.
Retired
ent
Address:
City
State:
Zip Code:
Work Phone Number
Patient Occupation
Emergency Contact Information
Contact Name:
Phone #
Relationship to Patient:
Parent
Spouse
Sibling
Other
Physician Information
Name of Referring Physician:
Telephone #:
RX Date:_____________
Eval/Treat:
# of visits:____________
Additional Questions
Date of Injury
Auto Related:
Work Related:
Accident Related:
Diagnosis/Body Part
Onset Date
Yes-State? ________
No
Yes
Yes
No
No
Adjuster name: _________________
Phone #:________________________
Post Surgical:
Yes /
No /
Unknown
Surgery Description:
_____________________________________________________
Surgery Date (if applicable): ______________
Have you any prior Therapy this year?
Yes
No
How did you hear about us?
(PT/OT/SP or Chiropractic)
MEDICARE ONLY- Additional Questions
If Medicare, are you currently receiving Home Health Service?
Yes
No If yes, Name of Agency ? ________________________
If Yes, what type of Home Health Services are you receiving? ________________________________ Last Date of Service__________
If Medicare, have you received PT, OT or Speech services since the first of the year?
Yes
No
•
If Yes, do you know if you have exceeded your Medicare Therapy Cap amount?
Yes
No
•
Are you aware of any partial amount used since the first of the year? $__________.
•
If Yes, please bring in any billing information from your previous therapy, or contact your previous provider for the
information. Please bring the Medicare benefit summary you receive from Medicare.
Appointment Date:
Time:
Therapist:
Patient, Please initial here if the above information is complete
Intake Completed By: ________________________ Date:______
and correct _____________________________Date:_________
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Parent category: Medical