PT Pack

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Save time by printing out the Patient intake forms and filling out the information requested, by clicking the link below.  You can fax forms to 678-550-8063 or bring them in on your visit. 

Patient Intake Forms

PATIENT INFORMATION

NAME
DATE OF BIRTH

E-MAIL ADDRESS
CITY

STATE
ZIP

HOME PHONE
SOCIAL SECURITY#

OCCUPATION
ADDRESS

WORK ADDRESS
WORK CITY

WORK STATE
WORK ZIP

WORK PHONE
EMPLOYER

CELL PHONE
REFERRING MD

PRIMARY CARE PHYSICIAN

HOW DID YOU HEAR ABOUT US?

EMERGENCY DATA

IN CASE OF EMERGENCY CONTACT:
NAME
PHONE NUMBER

ADDRESS
CITY

STATE
ZIP

RELATIONSHIP

INSURANCE DATA

NAME OF INSURANCE COMPANY
DOB

SUBSCRIBERS NAME
POLICY NUMBER

WAS INJURY DUE TO AN AUTO OR WORKERS COMP ACCIDENT?
IF YES, PLEASE FURNISH THE FOLLOWING.

DATE OF INJURY
FILE CLAIM NUMBER

INSURANCE COMPANY
CITY

ADDRESS TO SEND BILLS
STATE

ZIP
CLAIMS ADJUSTERS NAME

PHONE NUMBER
PRE-CERT CO.

SECOND PHONE NUMBER

I HEREBY AUTHORIZE PAYMENT TO BE MADE DIRECTLY TO EAGLE PHYSICAL THERAPY, FOR SERVICES RENDERED.
I HEREBY AUTHORIZE EAGLE PHYSICAL THERAPY TO RELEASE (OR OBTAIN) INFORMATION REGARDING MY PHYSICAL THERAPY EVALUATION AND TREATMENT AND RELATING BILLING INFORMATION TO (FROM) MY ATTORNEY, OR INSURANCE CARRIER FOR PURPOSES OF PROCESSING THIS CLAIM.
WE RESERVE THE RIGHT TO CHARGE FOR APPOINTMENTS CANCELLED WITHOUT 24HR NOTICE.

PATIENT MEDICAL HISTORY FORM

NAME:
DOB:

To help us better evaluate your condition please complete this form to the best of your knowledge. If you have any questions please ask for assistance. Thank you.

MEDICAL HISTORY: (Please check any conditions that apply to you. Items not checked are understood to be negative.)

High Blood Pressure
Abnormal Bleeding
Bowel or Bladder Problems

Heart Problem
Asthma
Autoimmune Disorder
Emphysema

Abnormal Heart Rate
Recent and Sudden
Weight Loss/Gain
Pacemaker
Thyroid Problem
(Hyper or Hypo)

Chronic Heartburn
Chronic Lung Problem
Diabetes (Medication Dependent?

Heart Palpitations
Arthritis
History of Ulcers
High Cholesterol

Cancer/Tumors (Where?)
Shortness of Breath

Seizures/Epilepsy
Osteoporosis
Night Sweats
Angina (Chest Pain)

Dizziness
Hearing Problems

Other:

Do you have a history of fractures?
Where?

Do you have a history of back/neck pain?
When?

Do you have any metal implants?
Where?

Do you smoke?
How much per day?

Do you exercise regularly?
How often?

Do you have any known allergies?
Please list

Are you allergic to latex?

Are you pregnant or suspect pregnancy?

MEDICATIONS: Please check if you are taking any of the following (Please list name of medications)
Blood Pressure Medication

Heart Medication

Anti-coagulants
(blood thinners)

Muscle Relaxants

Pain Killers

Diabetes Medication
(i.e.Insulin)

Steroids (Cortisone)

Anti-inflammatories

Other Medications

SURGERIES: Please list all surgeries, including date:

DIAGNOSTIC TESTS: Please check test(s) for current problem only.
( )X-rays ( )CT scan ( )MRI ( )Bone Scan ( )EMG ( )Bone Density ( )Blood Chemistry ( )Ultrasound
( )Other (please specify)

Have you seen anyone else for your current problem?
( )Physician/MD ( )Chiropractor ( )Podiatrist ( )Orthopedic Surgeon ( )Dentist ( )Neurologist/Neurosurgeon ( )Osteopath/DO ( )Physical Therapist
( )(please specify)

SYMPTOMS: In regards to your current condition:
How long have you been experiencing your symptoms:
How did your symptoms begin:
Have you had this problem before?

CHIEF COMPLAINT/ CURRENT CONDITIONS: Please describe:
Please rate your on a scale of 0-10. (0 no pain, 10 worst pain)

012345678910

Do you have any “pins and needles” or numbness in your extremities?

Do you have any weakness in your arms or legs?

Do you have any coordination or balance problems?

Do you have difficulty walking?

Do you experience dizziness or vertigo with a change in position?

Have you experienced headaches as a result of your condition?

I believe all information to be true and complete:

EFFECTIVE DATE

I acknowledge receipt of a copy of this Notice