... angina Numbness or tingling Pacemaker Dizziness or fainting High blood pressure Weakness Heart attack Weight loss or energy loss ... much for allowing Florida ...
Outpatient Rehabilitation Medical History
Date: ________________ Name: ______________________________________ Date of Birth: ___________ Referring Physician: _______________________________ Family Physician: _________________________ Occupation: ______________________________________ Are you currently working? _________________ Are you currently receiving Home Health Services? [pic] Yes [pic] No If yes, explain: __________________ Do you have or have you ever had any of the following? If yes, please explain below | |YES |NO | |YES |NO | |Asthma, bronchitis, emphysema| | |Severe or frequent headaches | | | |Shortness of breath/chest | | |Vision or hearing | | | |pain | | |difficulties | | | |Coronary Artery Disease or | | |Numbness or tingling | | | |angina | | | | | | |Pacemaker | | |Dizziness or fainting | | | |High blood pressure | | |Weakness | | | |Heart attack | | |Weight loss or energy loss | | | |Stroke/TIA | | |Bowel or bladder problems | | | |Congestive heart failure | | |Hernia | | | |Blood clot | | |Varicose veins | | | |Thyroid disease | | |Any metal implants | | | |Anemia | | |Joint Replacement Surgery | | | |Infectious disease | | |Neck injury/surgery | | | |Diabetes | | |Shoulder injury/surgery | | | |Cancer, chemotherapy, | | |Elbow/wrist/hand | | | |radiation | | |injury/surgery | | | |Arthritis | | |Back injury/surgery | | | |Osteoporosis | | |Knee injury/surgery | | | |Internal Stimulator | | |Leg/ankle/foot injury/surgery| | | |(brain/spinal) | | | | | | |Sleeping problems | | |Heart surgery | | | |Emotional/psychological | | |Are you pregnant? | | | |problems | | | | | | |Cortisone shot/epidural | | |Do you use tobacco? | | | |Epilepsy/seizures | | |Other: | | |
Latex allergy: Yes No Additional information: _________________________________________________________________ ____________________________________________________________________________ _________
Medication List-Please list ALL prescribed and over the counter medications you are currently taking:
• I am currently not taking any medication [pic] I have attached a copy of my medication list
|Name/dosage |Frequency |Name/dosage |Frequency | | | | | | | | | |
Fall Risk Assessment
| |YES |NO | |Are you seeing a physician for dizziness or balance problems? | | | |Do you have loss of balance or require assistance when getting up | | | |from sitting? | | | |Do you have difficulty walking without holding onto furniture or | | | |walls? | | | |Do you use a [pic] cane [pic] walker [pic] wheelchair? | | | |How many times have you fallen in the last 3 months? | |When and how did you last fall? |
| |YES |NO | |Do you have active tuberculosis (TB) or a history of recent TB? | | | |Do you have a history of MRSA? | | | |Do you have a history of Clostridium Difficile (C diff)? | | | |Do you have diarrhea? | | |
Do you feel afraid or threatened by someone close to you? [pic] Yes [pic] No [pic] I do not wish to answer
Chief complaint: _____________________________________ Symptom onset date: __________________ Cause: ____________________________________________________________________________ ______ Previous treatment for current problem? [pic] Chiropractor [pic] Physical Therapy [pic] Occupational Therapy Have you had any diagnostic tests for your current problem (X-rays, MRI)? [pic] Yes [pic] No Do you have any loss of sensation with your current problem? ______________________________________ Can you get comfortable at night? _____________________________________________________________ Have you had a similar problem before? [pic] Yes [pic] No If yes, how long ago? _______________________ Previous treatment? ________________________________________________________________________ Do you have pain related to your current problem? [pic] Yes [pic] No If yes, please continue below Indicate the location of your pain on the diagram below
Describe your pain:[pic] constant [pic] throbbing [pic] dull [pic] burning [pic] comes/goes [pic] numbness [pic] sharp [pic] tingling [pic] pressure [pic] aching What activities/positions increase your pain? __________________________ What activities/positions decrease your pain? __________________________ Does pain restrict you from certain activities? _________________________ Please circle your pain/discomfort level on the scale below: 0 1 2 3 4 5 6 7 8 9 10 No pain Worst pain
Cancellation Policy Outpatient Rehabilitation Services
Thank you very much for allowing Florida Hospital Memorial Medical Center to be a part of your healthcare team. In order to ensure that you have the very best outcome possible it is important that you attend your scheduled therapy sessions as prescribed by your physician and therapist. We ask that you please take a moment to read over our Cancellation Policy and to let us know if you have any questions.
Cancellations: Our policy allows for 3 cancellations within a rolling 30 day period. In the event you cancel your scheduled appointment more than 3 times in any 30 day period we will require a new order from your physician before we can see you again. Please remember our responsibility is to you, our patient, and if you are not coming in for your appointments as your physician and therapist have prescribed you will not achieve the optimal outcome. If you find that you must cancel your appointment, please contact us 24 hours prior to your scheduled appointment.
No Show: In the event you fail to show for your scheduled appointment with no notice given, more than two times, we will remove you from our schedule until a new order is provided from your physician.
In our rehabilitation center, you will be treated only by licensed professionals. Below are a few guidelines that will help us serve you on a timely basis.
1. Please arrive at your scheduled time. 2. Due to our limited area, we must ask that only the patient receiving therapy enter the gym area. Your guests may wait for you in the waiting area. There may be times, however, when your family may be asked to come into the clinic to be instructed in assisting you with home therapy. 3. It is your responsibility to verify your insurance coverage.
Once again, we thank you very much for allowing us to partner with you in your healthcare. We look forward to providing you with quality care and assist you in returning to a more active lifestyle.
Patient Signature: __________________________________________
Insurance Verification Florida Hospital Memorial Medical Center
Florida Hospital Memorial Medical Center is contracted with many HMO, PPO’s and other managed care organizations. Because we want to be as careful as we can to make sure that services to you are covered by your insurance company, we will make every attempt to verify your coverage and benefits.
We recommend, even if we are an “in-network” provider for your insurance that you contact your insurance company shortly before you expect to have services rendered and verify that Florida Hospital Medical Center is a covered provider for the services you are receiving.
If services received are not covered by your insurance plan, you will be responsible for all incurred charges.
___________________________________________ Signature of Receipt of the above information