E&L Associates Physical Therapy
MEDICAL HISTORY/SUBJECTIVE INFORMATION
A complete medical history is necessary for a thorough evaluation. Please answer the following questions.
Your Name:
Today’s Date:
Date of Birth:
Age:
Height:
Weight:
Do You Smoke?  Yes  No
Sex:  Male  Female If female, are you currently pregnant?  No  Yes If yes,  1st Trimester  2nd Trimester  3rd Trimester
Have you ever been diagnosed with any of the following?
Tuberculosis
 No  Yes
Cancer
 No  Yes
Arthritis
 No  Yes
Diabetes
 No  Yes
Hepatitis
 No  Yes
Stroke
 No  Yes
Heart Condition
 No  Yes
Epilepsy
 No  Yes
Respiratory Problems  No  Yes
Other: ______________________________________________________________________________________________________ __
Who referred you to physical therapy? __________________________ Primary Physician __________________________________
Tell Us About Your Condition
When did you first notice the pain or have functional problems due to the condition/injury? (Please provide approximate dates):
_______________________________________ Recent flare-up?  No  Yes If yes, when _________________________________
What activities are limited by this condition? (e.g. lift, reach) _____________________________________________________________
How did your injury/symptoms occur? ______________________________________________________________________________
________________________________________________________________________________________________________________
What do you expect to accomplish with physical therapy? ______________________________________________________________________
Are your symptoms:  Constant?
 Intermittent?
 Getting Better?
 Getting worse?
 Staying the same?
What makes your symptoms better?______________________________________
0-10 pain scale (0 = No Pain; 5= Moderate Pain; 10 = The Most Extreme Pain)
Worst pain rating: 0 1 2 3 4 5 6 7 8 9 10
Best pain rating: 0 1 2 3 4 5 6 7 8 9 10
For this injury, has your medical care included:(check those that apply)
 Surgery: When? ___/___/___ What kind?____________________________
 Injection: When? ___/___/___ Did it help?  Yes  No
 Other treatment:
 Physical therapy If yes, when? ___/___/___to ___/___/__
What was done?_______________________________________________
 Chiropractor If yes, when? ___/___/___to ___/___/___
What was done? ______________________________________________
 Medications: _________________________________________________
 X-ray ________________________
 MRI ____________________
 CT scan _______________________
 Other: ___________________
 Exercises: What kind? __________________________________________
Indicate on body diagrams where your symptoms
are located
 = Pain
III = Numbness
Comments: _______________________________
Work Information
Who is your employer? ______________________________ What is your job title/responsibilities? ______________________________
Are you currently working?  No  Yes If yes, numbers of hours per week __________
 Full Duty  Restricted Duty
How many total work days have you missed? ______ Do you have a case manager/QRC?  No
 Yes
Your Therapist Will Complete This Section
Critical work, ADL, or leisure activities affected: _______________________________________________________________________
 Lift/carry:  20 lbs. rarely to occasionally (low demand)  > 20 lbs., or > 1lb. constantly or > 10 lb. frequently (mod-high demand)
Where to where ________________ to __________________.
 Repetitive motions related to condition:  Occasional 1-33% (low demand)  Frequent to Constant 34-100% (mod-high demand)
 Static positions related to condition (mod-high):  Sit  Stand  Crouch  Kneel  Overhead work  __________________
 Leisure Activities:  None/minimally impact condition (low demand)  Moderate-high intensity, competitive (mod-high demand)
Overall functional demand (work/ADL/leisure)  Low Demand  Moderate-High Demand
Comments: ____________________________________________________________________________________________________
Additional Comments: ____________________________________________________________________________________________
Indicate either “Yes” or “ No” as to whether each of the following activities is difficult.
Drinking or Eating
 Yes
 No
 Yes
 No
 No
Balancing on both feet
Walking on: stairs, flat surfaces, inclines, uneven
surfaces, ladders
Sleeping Through the Night
 Yes
 Yes
 No
Dressing: Putting on or taking off
shoes, socks, shirt, jacket or pants
Maintaining static position of; Head
bent forward, arms overhead, arms
forward, or turning head
Getting in/out of: chairs, bed, car or
bath/shower
 Yes
 No
Lifting
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
Reaching: overhead, behind back,
downward for forward
Gripping, Holding tools or Opening
Jars
Picking up Small Objects
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
Housework / Yard work
 Yes
 No
Sitting
 Yes
 No
Recreational Activities
 Yes
 No
Standing
 Yes
 No
Have you fallen more than 1 time in the past year
 Yes
 No
Job Related Activities
 Yes
 No
Have you fallen and hurt yourself in the past year
 Yes
 No
Carrying
Bending, Kneeling Squatting
Driving a vehicle or ability to use gas/brake pedals
Caring for child or adult
Other:
PATIENT CONSENT TO TREAT
I hereby authorize and grant permission to E&L Associates Physical Therapy to carry out any assessment,
examination, procedures, treatments and interventions as may be necessary to assess and treat my condition or injury.
E&L Associates Physical Therapy and its staff agree to provide me with understanding information on:
 My diagnosis as known.
 The treatment being suggested
 Potential benefits, risks of treatment, and possible alternatives to the treatment
 Reasonable additional procedures which may be necessary
I hereby authorize and grant permission to E&L Associates Physical Therapy to communicate with any health care
professional that the rehabilitation of my condition may indicate and request any diagnostic or treatment information.
I hereby authorize and grant permission to E&L Associates Physical Therapy to release information regarding my
condition and my ability to return to normal activity or work to my insurance company  employer  (please check
all that apply).
I, ______________________________________________ understand the conditions and information as read and verbally provided and
voluntarily give my consent to the above authorizations.
__________________ _____________________________________________ _______________________________________
DATE
SIGNATURE
WITNESSED BY
FINANCE POLICY
We are committed to providing you with the best possible care and service. If you have medical insurance we
are anxious to help you receive your maximum allowable benefits. It is important you understand that:
1. If your Workers Compensation carrier has approved physical therapy services,
fees for approved services under Workers Compensation are established by the
state. Payment for those services is the responsibility of your Workers
Compensation carrier and not you.
2. Should your Workers Compensation carrier not approve any or all of the physical
therapy services, and you choose to have those services despite that fact,
payment for those services would be your responsibility and would be due at the
time services are rendered unless payment agreements exist and have been
approved in advance by our staff. We accept cash, checks, MasterCard, or Visa.
Please be advised that there will be a $25.00 service charge added to your
account for any returned checks.
If you are unable to keep your appointment, please call at least 12 hours in advance (exceptions for sudden
illness and emergencies) so that someone else may see the therapist in the time which had been reserved for
you. There will be a $40.00 fee for all no-show appointments which is due directly from you and payable at
the time of the next scheduled appointment. Should the account be referred for collection, the undersigned
shall pay reasonable collection expenses including attorney’s fees.
It is our policy that after a patient cancels or is a no-show for three (3) consecutive appointments, they are
automatically discharged from the program and must return to their physician to obtain a new prescription or
referral for physical therapy before resuming care.
If you have any questions regarding the above information or regarding payment, please do not hesitate to
ask us. We are here to help.
REMEMBER
1. Cancellations are made at least 12 hours in advance (except for sudden illness or emergencies).
2. There is a $40.00 fee for all no-show appointments due directly from the patient and payable at the time
of the next scheduled appointment.
3. No-show or cancellation of three (3) consecutive appointments will result in a discharge back to your
physician.
The undersigned certifies that he/she has been informed and has read the foregoing and is the patient, patient’s parent
or guardian, or duly authorized by the patient as the patient’s general agent, and that he/she accepts the terms
contained in this finance policy.
SIGNATURE: _____________________________ DATE: _____________________
EGGLETON AND LANGTON
PHYSICAL THERAPY MANAGEMENT SERVICES
PRIVACY NOTICE
Effective Date: March 1, 2003, Revised yearly
THIS ABBREVIATED NOTICE BRIEFLY DESCRIBES HOW HEALTH INFORMATION ABOUT YOU
PLEASE REVIEW IT CAREFULLY
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment: We may use health information about you to provide you with health care treatment or
services. We may disclose health information about you to personnel who are involved in taking care of you.
For Payment: We may use and disclose health information about you so that the services you receive from us
may be billed to and payment collected.
For Health Care Operations: We may use and disclose health information about you for operations that are
necessary to run our practice.
Health-Related Services and Treatment Alternatives: We may use and disclose health information to tell
you about health-related services.
Research: Under certain circumstances, we may use and disclose health information about you for research
purposes.
Threat to Health or Safety: We may use and disclose health information about you when necessary to prevent
a serious threat to your health and safety or the health and safety of the public or another person.
Military and Veterans: If you are a member of the armed forces or separated/discharged from military
services, we may release health information about you as required by military command authorities or the
Department of Veterans Affairs.
: We may release health information about you for workers compensation or similar
programs. These programs provide benefits for work-related injuries or illness.
Health Oversight Activities: We may disclose health information to a health oversight agency as authorized
by law.
Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose health information
about you in response to a court or administrative order etc..
Law Enforcement: We may release health information if asked to do so by a law enforcement official.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU.
Right to Inspect and Copy: You have the right to inspect and copy health information that may be used to
make decisions about your care.
Right to Amend: If you feel that health information we have about you is incorrect or incomplete, you may ask
us to amend the information.
Right to an Accounting of Disclosures: You have the right to request a list accounting for any disclosures of
your health information we have made, except for uses and disclosures for treatment, payment, and health care
operations, as previously described.
Right to Request Restrictions: You have the right to request a restriction or limitation on the health
information we use or disclose about you for treatment, payment, or health care operations.
Right to Request Confidential Communications: You have the right to request that we communicate with
you about health matters in a certain way or at a certain location.
Right to a Paper Copy of This Notice: You have the right to obtain a paper copy of this notice at any time.
We reserve the right to change this notice at any time. We will post a copy of the current notice in our facility.
For questions or to report a suspected violation contact Dennis Langton, Privacy Officer, at (619) 589-2606
I have read and understand the Protected Health Information Privacy Notice. I understand that upon request a
copy of both this abbreviated notice and the complete notice will be provided me.
Patient Name :_________________________ Patient Signature: ____________________________________
Date: ______________________
JOINT MOBILIZATION INFORMATION
The information below is to inform you of the potential benefits and precautions regarding a
treatment technique commonly performed in physical therapy.
What is joint mobilization?
It is a hand’s on treatment procedure that is performed by physical therapists to correct soft
tissue and joint problems. It consists of a passive range of motion to isolated peripheral and
spinal joint segments.
Joint mobilization to any of the joints of the spine or extremities can produce the following
benefits:
1. Correct the position of a spinal segment or peripheral joint position to a more normal
state.
2. Increase joint flexibility and motion.
3. Decrease pain and reduce muscle spasm.
4. Help a joint return to normal function.
When can it not be done?
Mobilization cannot be done on a patient who is on anticoagulant (Blood thinning) drugs or has
a fracture where the joint mobilization is being done.
Which health care professionals can do mobilization procedures?
Osteopaths, Chiropractors, Medical doctors and Physical Therapists are the health care
professionals who can perform joint mobilization.
What are my options for appropriate treatment besides joint mobilization?
Modalities including heat, cold, laser, ultrasound, electrical stimulation, soft tissue mobilization
and myofascial release techniques and therapeutic exercise are all treatments that are used in
concert with joint mobilization but are also appropriate if done without mobilization.
Please ask your therapist to answer any questions you have about this highly effective treatment.
I have read and understand the benefits, risks and precautions of joint mobilization.
________________________________________
__________________________________
Patient signature and date
Witnessed by