Exercise Based Rehabilitation Form Patient Intake Form Excercise Based Rehabilitation Save time and fill out your intake form before your appointment! Please fill out the form below. Items marked with an asterisk are required when submitting. Patient Information Today's Date* First Name* Last Name* MI Home Address* City* State* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingWashington DCARMED FORCES AFRICA CANADA EUROPE MIDDLE EASTARMED FORCES AMERICA (EXCEPT CANADA)ARMED FORCES PACIFIC Zip* Date of Birth* Marital Status SDM Gender FemaleMale Cell Phone* Home Phone Work Phone Email Address* Emergency Contact and Phone Contact Preference Home Cell Email Work Mail Referring Physician Secondary Physician Informed Consent to Evaluate / Treat By my signature, which appears below, I hereby grant my permission for and request that I be evaluated, andtreated by the physical therapist and/or kinesiotherapist, according to the plan of care developed by the physical therapist and/or kinesiotherapist and prescribed by my physician in consultation with the therapist(s). I understand that the purpose of this program is to enhance my recovery from an illness, injury or surgery. It has been explained to me that there exists the likelihood of changes in the treatment program as my condition changes and I hereby grant my permission for all modifications and changes to the treatment program deemed necessary by the therapist(s). The procedures and or modalities to be used have been explained to me and I have had the opportunity to ask any questions I had, and acknowledge that I have received answers that are satisfactory to me. I understand that the success of this, or any other medical treatment program depends on my involvement and cooperation with the program including regular attendance at all treatment sessions and conscientious follow through with any home exercises or procedures which may be prescribed by the therapist(s). I understand what is expected of me as a patient and agree to cooperate to the best of my ability. I hereby attest that I have read and agreed to all statements made above and that my participation in this physical and or/ occupational therapy treatment program is fully voluntary. Patient Signature: Hold down left-click on your mouse and drag the cursor over the white box to draw your signature. Authorization to Disclose Health Information Automatically includes your Doctor, your spouse (if applicable) and the insurance company. Patient Name* 1. I authorize the use or disclosure of the above named individual’s health information as described below. The following individual or organization is authorized to make the disclosure: 2. The type and amount of information to be used or disclosed is as follows: Evaluation(s) Progress Notes Most recent history and physical Most recent discharge summary Entire Record Other Description if Other: 3. I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse. 4.This information may be disclosed to and used by the following individuals or organizations (Include Name, Phone, Email, And Address): 5. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the Healthcare Management office. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. If I fail to specify an expiration date, event or condition, this authorization will expire in 12 months. 6. I understand that authorizing this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it potential for an unauthorizedre disclosure and the information may not be protected by federal confidentiality rules. Signature of Patient or Legal Representative: Hold down left-click on your mouse and drag the cursor over the white box to draw your signature. Billing Agreement Sessions will be made by appointment at your convenience and the availability of the therapist. Sessions are based on a 50-minute hour. A refund may be given only with the written consent of Just Be Fit, Inc. under the following circumstances: A patient relocates to another city or location out side the counties of Cook, Lake or Du Page Illinois. The Medical condition a patient suffers from makes it impossible to continue with their therapist. In this case, a physician’s written notification is required. Sessions which remain unused for a period of one (1) year after the date of purchase will not be honored. # OF SESSIONS PRICE PER SESSION TOTAL COST 1 $120.00 $120.00 5 $110.00 $550.00 10 $95.00 $950.00 20 $90.00 $1800.00 I authorize continued payment to be charged to my credit card when my package has been used. YesNo I authorize Just Be Fit, Inc to charge my credit card for modalities/services not covered by my EBR package. YesNo I have read, understand and accept these policies as they are related to my rehabilitation package called (Exercise Based Rehabilitation.) Cancellation / Missed Appointment Policy Please be aware that if you need to cancel your therapy appointment a 24 hour notice is required. We appreciate as much advance notice as possible; therefore calls made later than 24 hours prior to your scheduled appointment date and time will be billed to you personally, the cost of a missed appointment ( your EBR package price ) , if you do not provide at least 24-hours notice of a cancellation. Also, if you miss THREE consecutive scheduled therapy appointments without calling to cancel or reschedule your appointment you will be discharged immediately from our Exercised Based Rehabilitation Program. This policy will be enforced after your initial therapy appointment. I agree to pay the fees outlined in this policy. Initials:* Medical History Have you ever had, or do you currently have, any of the following? Please check all that apply. Bronchitis Asthma Aneurism Anemia Alcohol Abuse Problems Chronic Obstructive Pulmonary Disease Cerebral Palsy Coronary Artery Disease/Heart Disease Diabetes Type I, Type II Emphysema Fibromyalgia Gout Hearing Loss Hemorrhoids High Blood Pressure / Hypertension High Triglycerides Hypoglycemia Kidney Disease Lung Disease Muscular Dystrophy Osteoporosis Paralysis Spina Bifida TMJ Tumors Varicose Veins Allergies Arthritis (Osteo/Rhuematoid/AS) Angina Back/Spinal Injury Cancer Cerebral Vascular Accident/Stroke Coronary Vascular Disease Circulatory Problems Embolism Epilepsy Gastroinestinal/Stomach Problems Head Injury Heart Attack Hernia High Cholesterol Hyperglycemia Crohn's Disease Joint Problems (Knee/Shoulder/Hip/Back) Low Blood Pressure Multiple Sclerosis Nervous/Emotional Tension Parkinson's Disease Poliomyelitis Spinal Cord Injury Thyroid Problems TBI Please comment here on any marked answers from above: Have you recently experienced any of the following? Please check and provide a description to all those that apply. Back/Leg Pain Blurred Or Double Vision Bowel / Bladder Changes Brain Fog Calf Pain WIth Exercise Change In Speech Pattern Chest Pain or Pressure Constant Pain Unrelieved By Rest or Movement Difficulty Keeping Balance Difficulty Sleeping Difficulty Swallowing Dizziness, Fainting, or Blackouts Falls Fatigue Irregular Heartbeat Headaches or Migraines Muscle Pain at Rest Muscle Pain with Exertion Numbness or Tingling in Arms, Hands, or Legs Ringing In Ears Shortness of Breath Stroke Swollen, Stiff, or Painful Joints Tremors Unexplained Weight Gain Unexplained Weight Loss Unusual Skin Coloration Unusual Weakness or Fatigue Wound That Does Not Heal Other Problems Current Height Current Weight Have you undergone a complete medical exam within the last year? YesNo Are you currently taking any medication? If please provide a list of details below. NoYes Please list any homeopathic, herbal, vitamin, and/or mineral products including THC or CBD products that you are currently taking for the treatment of any condition or deficiency. Please describe any surgery and/or hospitalizations. Identify any assistive devices you are currently using (cane, brace, etc.), whether the device was prescribed by a physician, and the reason for the device: Please identify any past or ongoing treatments by a physician, physical therapist, chiropractor, massage therapist, acupuncturist, etc: Have your physician ever advised you against exercise? If yes, please provide an explanation. YesNo WOMEN'S HEALTH Are You Pregnant? YesNo When was your last menstrual cycle? Check the one that best describes your situation: PremenopausalPostmenopausalMenopausal List any symptoms that accompany your menstrual cycle: Interview Reason For Today's Visit: *If your visit is related to an injury, check the appropriate response in the box below. If it is not related to an injury, skip this section. The injury is due to one of the following: Car AccidentWork InjurySports InjuryFallOther The injury occurred at: HomeWorkSchoolOther Is legal action / litigation pending due to this injury? If yes, please provide a brief description. YesNo Date of Onset / Injury Symptoms Location of Symptoms RightLeftBothNA Check each characteristic that best describes your problem: Quality Sharp Throbbing Aching Burning Cramping Duration Infrequent Constant Hourly Daily Weekly Context Worsening Recurrent More Frequent Symptom Aggravation Activity Positive Change Repetitive Motion Fatigue Other Severity Mild Moderate Severe Timing After Activity Walking Running Stairs Squatting Pivoting Overhead Use Throw Life Other Symptom Relief Rest Heat Cold Elevation Brace Injection Medication Physical Therapy Other Treatment: Describe treatment and response for current problems Have You Had A Problem Here Before? If yes please describe the problem and prior treatment. YesNo Have you had any diagnostic tests for this problem? If yes, what and where? YesNo Do You Have a Copy OfThe Test Results? YesNo Did You Bring The Test Results With You? YesNo Has A Physician Recommended Surgery? If so, please provide the name(s): YesNo What is the level of your pain on a scale of 0 - 10? What Are Your Limitations? In What Activities Is The Pain (Or Disability) Manifested? What Was Your Activity Level Prior? What Are Your Goals From Physical Therapy? Signature: Hold down left-click on your mouse and drag the cursor over the white box to draw your signature. We appreciate your courtesy and thank you for your cooperation. Just Be Fit, Inc looks forward to providing our Physical Therapy services to you. Should you have any questions concerning our professional services or office procedures, please ask. Sincerely, Just Be Fit, Inc Management Notice of Health Information Practices This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Understanding Your Health Record/Information Each time you visit a hospital, physician or other healthcare provider a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment and a plan for future care or treatment. This information often referred to as your health medical record serves as a: Basis for planning your care and treatment Means of communication among may health professionals who contribute to your care Legal document describing the care you received Means by which you or a third-party payer can verify that services billed were actually provided A tool in educating health professionals A source of data for medical research A source of information for public health officials charged with improving the health of the nation A source of data for facility planning and marketing A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve Understanding what is in your record and how your health information is used helps you to: Ensure its accuracy Better understand who, what, when and why others may access your health information Make more informed decisions when authorizing disclosure to others Your Health Information Rights Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to: Request a restriction on certain uses and disclosures or your information as provided by 45 CFR 164.522 Obtain a paper copy of the notice of information practices upon request Inspect and copy your health record as provided for in CFR 164.525 Amend your health record as provided in 45 CFR 164.528 Obtain as accounting of disclosures of your health information as provided in 45 CFR 164.528 Request communication of your health information by alternative means or at alternative locations Revoke your authorization to use or disclose health information except to the extent that action has already been taken Our Responsibilities This organization is required to: Maintain the privacy of your health information Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you Abide by the terms of this notice Notify you if we are unable to agree to a requested restriction Accommodate reasonable requests you may have to communicate health information by alternative or at alternative locations We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you’ve supplied us. We will not disclose your health information without your authorization, except as described in this notice. For more information or to Report a Problem If you have questions and would like additional information, you may contact Just Be Fit, Inc. at (847) 444-1348. If you believe your privacy rights have been violated, you can file a complaint with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint. Examples of Disclosures for Treatment, Payment and Health Operations We will use your health information for treatment. For example: Information obtained by your physical therapist will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of your physical therapist. Your therapist will then record the actions he/she took and their observations. In that way the physician will know how you are responding to treatment. We will also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you’re discharged from therapy. We will use your health information for payment For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures and supplies used. We will use your health information for regular health operations. For example: Members of the medical staff, the corporate compliance officer, or other members of our physical therapy staff may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide. Business Associates: There are some services provided in our organization through contacts with business associates. Examples include our billing service. When these services are contracted, we may disclose your health information to our business associate so that the can perform the job we’ve asked them to do. To protect your health information, however, we require the business associate to appropriately safeguard your information. Communication with family: Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment relates to your care. Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information. Marketing: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Workers Compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law. Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability. Law Enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public. Effective Date: 3-20-13
