CampbellUniversityInc.StudentProBonoClinic
NewPatientPaperwork
Name:____________________________DOB:____/_____/_____
Age:_____
Gender:M/FOccupation:____________________
Phonenumber:_____________________email:________________________________
Address:______________________________________________________________
Reasonforvisit:______________________________Dateofonset/injury:___________
Haveanydiagnostictestshavebeenperformedforthisproblem?(circleallthatapply):
x-raysBonescanDopplerultrasoundMRIEMGCTScanBloodworkOther:___________
Pleasecirclewhereyouhurt:
Sinceithasstarted,painis(chooseone):
gettingworseimprovingunchanged
Describeyourpain(circleallthatapply):
sharpdullachingsorethrobbing
crampingburningstabbing
squeezingconstantintermittent
Whatmakesitworse:
___________________________________
Whatmakesitbetter:
___________________________________
Rateyourpainon0-10scale(0isnopain,
10istheworstyoucanimagine):
Present:012345678910
Listallmedications/supplements/vitamins/over-the-counteryoucurrentlytakeincluding
dosageandfrequency:
Name:_________________Frequency:_____________________Dose:_________________
Name:_________________Frequency:_____________________Dose:_________________
Name:_________________Frequency:_____________________Dose:_________________
Name:_________________Frequency:_____________________Dose:_________________
Name:_________________Frequency:_____________________Dose:_________________
Listallallergiesyoumayhave:____________________________________________________
CampbellUniversityInc.StudentProBonoClinic
NewPatientPaperwork
Pleasecircleyesornoifyouhaveorhavehadanyofthefollowingconditions:
Yes/No
Yes/No
Smoke/chewtobacco
Y/N
Emphysema Y/N
Packsperday:____
COPD Y/N Useofillegalsubstances
Y/N
Asthma
Y/N
Drinkalcoholicbeverages Y/N
Kidneydisease
Y/N
Amountperweek:____
Stroke
Y/N
Highbloodpressure Y/N
Depression Y/N
Highcholesterol
Y/N
Lupus Y/N
Bowel/bladderdysfunctionY/N
Fibromyalgia Y/N
Acidrefluxorulcers Y/N
Osteoarthritis
Y/N
Thyroiddisorder
Y/N
Rheumatoidarthritis Y/N
Bleedingdisorder Y/N
Headachesormigraines
Y/N
Seizures/epilepsy Y/N
Dizzinessorfainting Y/N
Lymedisease Y/N
Cancer(site:__________) Y/N
Diabetes
Y/N
Recentinfection
Y/N
Heartattack Y/N
Recentanticoagulantmedicineuse Y/N
Cardiacbypass
Y/N
Recentantibacterialmedicineuse Y/N
Cardiacstents
Y/N
Consistentsteroidalmedicineuse Y/N
Angina/chestpain Y/N
Multiplesclerosis Y/N
Hepatitis
Y/N
Congestiveheartfailure
Y/N
Inthepast3monthshaveyouexperienced
Yes/No
Yes/No
Persistentpainatnight
Y/N
Changein/problemswith Y/N
Fevers,chillsornightsweats
Y/N
bowel/bladder
Unexplainedweightloss
Y/N
Changesinhearing Y/N
Unwarrantedfatigue Y/N
Changesinmentalabilities Y/N
Unusuallumpsorgrowths Y/N
Frequentorsevereheadaches
Y/N
Shortnessofbreath Y/N
withnohistoryofinjury
Constantandseverepaininleg/armY/N
Problemswithswallowing Y/N
Frequentorsevereabdominalpain Y/N
Speechchanges
Y/N
Frequentnauseaorvomiting
Y/N
Changesinvision
Y/N
Ringinginears
Y/N
Problemswithbalance/falling
Y/N
Suddenunexplainedweakness
Y/N
Faintingspells/blackouts
Y/N
TinglingornumbnessinbothofyourY/N
Newmolesorskinlesions Y/N
Armsorbothlegs
PatientSignature:__________________________________________________________________________________
(Guardianifpatientisunder18yearsold)
Date:____________________
CampbellUniversityInc.StudentProBonoClinic
NewPatientPaperwork
Attendance/NoShowPolicy
WelcometoCampbellUniversityInc.StudentProBonoClinic.Weunderstandthatsometimes
youwillneedtoeitherchangeorcancelascheduledappointment.Inordertoprovidecarefor
allofourpatients,wedohaveanattendancepolicythatweaskyoutoreviewandsign.
1. Ifyouareunabletoattendascheduledappointmentpleasecalltheclinicassoonasyou
areable.Wedoaskfor24-hoursnoticeasthismayallowthestafftoprovideservices
foranotherpatientduringthecanceledtime.
2. Ifyouaremorethan20minuteslateforyourappointment,youwillbeaskedto
rescheduleyourappointment.
3. Ifyoudonotshowfor3appointmentswithoutgivingacancellationnotice,
rehabilitationserviceswillbediscontinued.
Ifyouhaveanyquestionsregardingthispolicy,pleasespeakwithyourphysicaltherapist.
Ihavereadandunderstandtheabovepolicy.
_________________________________________ _______________
ClientSignature
Date
CampbellUniversityInc.StudentProBonoClinic
NewPatientPaperwork
CONFIDENTIALITYAGREEMENT
CampbellUniversityInc.StudentPhysicalTherapyClinicprovidesphysicaltherapystudents
withtheopportunitytolearncareofpatientsthroughexperience,observationand
participation.Perlawsandprofessionalethics,itisrequiredthatallhealthsciencestudents
maintainconfidentialityofpatientinformationtothegreatestextentpossible.Theclinic
upholdsthiscommitmenttoconfidentialitytothehighestdegree.Thereareafewscenariosin
whichconfidentialinformationmaybedisclosed.
1. Whenupholdingconfidentialitymayresultinphysicalharmtomyselforothers.
2. Intheinstanceinvolvingabuse(physical,sexual,psychological,etc.)ofanyindividual.
AUTHORIZATIONTORELEASEINFORMATION(HIPAA)
Iunderstandaspartofmycare,CampbellUniversityInc.StudentPhysicalTherapyClinicisin
possessionofhealthrecords.Underlaw,theuseanddisclosureoftheserecordsisprohibited.
Signingthisformgivesauthorizationtostudentsandfacultyoftheclinictouseanddisclosemy
healthinformationinordertocarryoutpropertreatmentaswellasassistinacademic
advancement.Myhealthinformationwillnotbedisclosedtoanyoneelseunlessindicated
below.IfCampbellUniversityInc.StudentPhysicalTherapyClinicneedstocontactme
regardingservicesprovided,Iauthorizethiscommunication.Ihavetherighttorefusetosign
thisauthorizationofreleasebutindoingso,theclinichasarighttodeclinetoprovideme
services.
Name:_____________________________ DateofBirth:___/___/_____
[]IauthorizethereleaseofinformationobtainedfromCampbellUniversityInc.Student
PhysicalTherapyClinictothefollowing:
[]Spouse____________________________
[]Child(ren)__________________________
[]Other_____________________________
[]MyhealthinformationisNOTtobereleasedtoanyone
ThisAuthorizationtoReleaseInformationwillremainineffectuntilterminatedbymein
writing.
ContactInformation
Pleasecommunicatewithmeby:
[]Homephone________________
[]Cellphone__________________
[]Email_____________________
Thebesttimetoreachmeis(circle):SunMonTueWedThursFriSat
MorningAfternoonEvening
Signed:___________________________________Date:___/___/_____
CampbellUniversityInc.StudentProBonoClinic
NewPatientPaperwork
ReleaseofLiabilityandAgreementtoTreat
Inexchangeforparticipation/treatmentintheCampbellUniversityInc.StudentPhysical
Therapyclinic,Iagreetothefollowing:
1. Iagreetoadheretoanywrittenrulesorwarningswithintheclinic.
2. Iagreetoadheretoanyoralinstructionsgiventomebyeitherthephysicaltherapy
studentsortheDPTfaculty.
3. IunderstandtherearecertainrisksassociatedtotheabovedescribedactivitiesandI
assumefullresponsibilityforpersonalinjury.Ifaninjuryweretooccurbyfaultofmy
own,myfamily,theDPTstudents,theDPTfaculty,orthirdparties,IreleaseCampbell
UniversityandtheCampbellUniversityDPTprogramfromtheinjury,lossordamage
arisingfrommyuseoforpresenceuponthefacilitiesofCampbellUniversity.
4. IunderstandthatthetherapyIwillreceivewillbeprovidedbyphysicaltherapystudent
whoaresupervisedbylicensedphysicaltherapists.
5. IunderstandthatthisclinicisrunfullybyvolunteersandIwillnotbechargedforany
serviceIreceive.
6. IgivemypermissionforCampbellUniversityDPTstudentstocareformeandprovide
physicaltherapyservices.
Ihavereadalloftheaboveconditionsandunderstandthem.Ifurtherunderstandthatby
signingthisrelease,Ivoluntarilysurrendercertainlegalrights.
Signature:________________________________________Date:___/___/_____
PhotoRelease
Igivepermissiontousemyimageasmarkedinthesection(s)below.Thisincludesthe
display,distribution,publication,transmission,orotheruseofimages,photographs,or
videostakenofmyself.Theseimageswillbeusedinbrochures,newsletters,videos,digital
images,etc.suchasontheCampbellUniversityDPTprogramwebsite.
[]Idenypermissiontousemyimageatall.
[]Igrantpermissiontousemyimageinthefollowingscenarios(markallthatapply):
[]LimitedUsage:MyimageisallowedtobeusedwithintheDPTprogramonlyandNOT
withinthelargercommunity
[]LimitedUsage:Myimageisallowedtobeusedineducationalmaterialsonly.This
includeswithintheDPTprogramandthelargercommunity.
[]LimitedUsage:Myimageisonlytobeusedonprintedmaterial,NOdigitalorvideouse.
[]UnrestrictedUsage:Igiveunrestrictedusageofmyimagestobeusedinprint,video,and
digitalmedia.Iagreethatmyimageswillbeusedforavarietyofpurposes.Idonotrequire
furthernotificationinordertousemyimages.Iunderstandthatmylastnamewillnotbe
usedinconjunctionwithanyofmyimages.
Signature:_______________________________________Date:___/___/_____