Physical Therapy Intake Form - Freedom Performance

Email

* Patient's First Name

* Patient's Last Name

* Patient's Date Of Birth

* Patient's Gender

Parent/Guardian 1st & Last Name (if patient is under 18)

* Contact Phone Number

* Contact Email

* Preferred Method of Contact & Best Time Of Day To Contact

Phone Call

Text

Email

Early Morning (5am-7am)

Morning (8am-11am)

Afternoon (11am-3pm)

Evening (3pm-6pm)

Late Evening (7pm-8pm)

* Payment Method

* I understand that payment for my physical therapy services are due at the time of booking and non-refundable. If using insurance, I understand that if my insurance does not submit payment to Freedom Performance for services rendered, I am personally responsible for the full amount due.

* Have you had any unexplained weight loss in the last month?

* Do you exercise regularly?

How many years of experience do you have exercising?

What type of training are you doing currently?

* Do you have a gym membership currently?

What Is The Name of Your Gym?

* Have you ever done any Olympic Lifting?

* Do you have difficulty sleeping?

* Do you experience episodes of dizziness?

* How many falls have you had in the last 12 months?

Were you injured in any of the falls?

* I Give Permission To Give My Medical Information to A Qualified Medical Provider, If I Or My Dependents Are In Need of Medical Care.

* Please note that if you fail to show up for a scheduled appointment or cancel within 24 hours of the appointment time, you will be charged the full amount of $159, regardless of insurance coverage. To ensure this policy is enforced, we require a credit card to be kept on file. I agree to and understand this policy and will submit an online credit card authorization form.

* What is the reason for your visit?

* Are You Taking Blood Thinners?

* Are you or is there a chance you are pregnant?

* Are you aware of any problems or have any concerns with your immune system?

* Do you have any known disease or infection that can be transmitted through bodily fluids?

* Dry needling (DN) is a skilled technique performed by a physical therapist accidental puncture of a lung (pneumothorax). If this were to occur, it may require a chest x-ray and no further treatment. The symptoms of shortness of breath may last for several days to weeks. A more severe lung puncture, while rare, may require hospitalization. Other risks may include bruising, infection or nerve injury. It should be noted that bruising is a common occurrence and should not be a concern. The monofilament needles are very small and do not have a cutting edge; the likelihood of any significant tissue trauma from DN is unlikely. Patient's Consent I have read and fully understand this consent form and attest that no guarantees have been made on the success of this procedure related to my condition. I am aware that multiple treatment sessions may be required, thus this consent will cover this treatment as well as subsequent treatments by this facility. All of my questions, related to the procedure and possible risks, were answered to my satisfaction. My signature below represents my consent to the performance of dry needling and possible risks.

1st Time Visit - Freedom Performance Physical Therapy Intake