Ultimate Therapy
40900 Merchants Lane, Suite 202
Leonardtown, MD 20650
Patient Information
______________________
_____________________
______
Last Name
First Name
Age
Sex M F
____________________________________________________________________________________
Street Address
City
State
Zip
(____)_________________ (____)_____________
_________________________________________
Home Phone
Email Address
Cellular
________________________________________________________________(_____)________________________________
Occupation
Employer Name
Phone #
______________________________(____)___________________________________________________________________
Emergency Contact Person
Phone #
(if minor) Parent/Guardian Name and Signature
Social Security # ________________________ Date of Birth ______/_______/_______
Work Status:
currently employed
retired
Marital Status:
disabled (__ total or __ temporary)
S
M
D
W
student __PT __FT
How did you hear about us? _______________________________________________________________
Medical Information
______________________________________________
Referring Physician
____________________ ___________________
Phone
Fax
_______________________________________________ __________________ ___________ ______________
Referring Physician Street Address
Injury ____
Illness____
City
Accident ____
State
Zip Code
Date of onset ___________________
Payment Information
I am paying by:
____self pay
____ Bill my insurance directly My copay/coinsurance is $_______.
My deductible is $_______.
Primary Insurance
Subscriber Name: ____________________________________________ Date of Birth: ___________________
Subscriber Address: __________________________________________________________________________
Insurance Name: _________________________________ Policy# __________________ Group# ___________
Relationship to Patient: ____ self
___spouse
___ parent
Secondary Insurance
Subscriber Name: ____________________________________________ Date of Birth: ___________________
Subscriber Address: __________________________________________________________________________
Insurance Name: _________________________________ Policy# __________________ Group# ___________
Relationship to Patient: ____ self
___spouse
___ parent
Office Use Only
NPI ____________________
Diagnosis Codes: ______.____; ______.____; ______.____; ______.____
Assignment of Benefits to Ultimate Therapy
Patient Name:____________________________________________________________
I hereby instruct and direct _____________________ insurance company to pay by
check made out and mailed to:
Ultimate Therapy
P.O. Box 2327
Leonardtown, Md 20650
(301) 997-1155
If my/this current policy prohibits direct payment to doctor, I hereby also instruct and
direct you to make out the check to me and mail it to the above address for the
professional or medical expense benefits allowable, and otherwise payable to me under
my current insurance policy as payment toward the total charges for the professional
services rendered.
This is a direct assignment of my rights and benefits under this policy.
This payment will not exceed my indebtedness to the above-mentioned assignee, and I
have agreed to pay, in a current manner, any balance of said professional service charges
over and above this insurance payment.






A photocopy of this Assignment shall be considered as effective and valid as the
original.
I authorize the release of any medical or other information pertinent to my case to
any insurance company, adjuster, or attorney involved in this case for the purpose
of processing claims and securing payment of benefits.
I authorize the use of this signature on all insurance submissions.
I authorize Ultimate Therapy to deposit checks made in my name.
I authorize Ultimate Therapy to initiate a complaint to the Insurance
Commissioner for any reason on my behalf.
I understand that I am financially responsible for all charges whether or not paid
by insurance.
Dated this ______ day of ______________, 20_____.
___________________________________
Signature of Policyholder
___________________________________
Signature of Claimant, if other than Policyholder
______________________________
Witness
Ultimate Therapy
40900 Merchants Lane, Suite 202
Leonardtown, MD 20650
Ph: 301-997-1155 Fax: 301-997-1199
Statement of Privacy Notice
Effective October 1, 2007
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT OUR
OFFICE AT THE ADDRESS OR PHONE NUMBER AT THE TOP OF THIS NOTICE.
Who will follow this notice?
The information privacy practices in this notice will be followed by:
Any healthcare professional that treats you at any of our locations.
While each of these facilities and affiliates operates independently, they may share your health
information for coordination of care treatment, payment and healthcare operations purposes.
Our pledge to you:
We understand that medical information about you is personal. We are committed to
protecting medical information about you. We create a record of the care and services you
receive to provide quality care and to comply with legal requirements. This notice applies to all
of the records of your care generated by any of the separate facilities and providers described
above. We are required by law to:
Keep medical information about you private;
Give you this notice of our legal duties and privacy practices with respect to
medical information about you; and
Follow the terms of the notice that is currently in effect.
How we may use disclose medical information about
you:
We may use and disclose medical information about you without your prior
authorization for treatment (such as sending medical information about you to a
specialist as part of a referral) (this includes psychiatric or HIV information if
needed for the purposes of your diagnosis and treatment); to obtain payment
for treatment (such as sending billing information to your insurance company or
Medicare); and to support our healthcare operations (such as comparing patient
data to improve treatment methods or for professional education purposes)
(Note: only limited psychiatric or HIV information may be disclosed for billing
purposes without your authorization). If you are treated in a specialized
substance abuse program, your special authorization will be needed for most
disclosures other than emergencies).
Other examples of such uses and disclosures include contacting you for
appointment reminders and telling you about recommending possible
treatment options, alternatives, health related benefits or services that
may be of interest to you. We may also contact you to support our fundraising
efforts.
We may use or disclose medical information about you without your prior
authorization for several other reasons. Subject to certain requirements, we
may give our medical information about you, without prior authorization for
public health purposes, abuses or neglect reporting, health oversight
audits or inspections, medical examiners, funeral arrangements and
organ donation, workers’ compensation purposes, emergencies, national
security and other specialized government functions, and for members of
the Armed Forces as required by Military Command authorities. We also
disclose medical information when required by law, such as in response to a
request from law enforcement in specific circumstances, or in response to
valid judicial or administrative orders or other legal process.
Under certain circumstances, we may use and disclose health information
about you for research purposes, subject to a special approval process. We
may also allow potential researchers to review information that may help them
prepare for research, so long as the health information they review does not
leave our facility, and so long as they agree to specific privacy protections.
We may disclose medical information about you to a friend or family member
whom you designate or in appropriate circumstances, unless you request a
restriction. We may also disclose information to disaster relief authorities so that
your family can be notified of your location and condition.
Other uses of Medical Information:
In any other situation not covered by this notice, we will ask for your written
authorization before using or disclosing medical information about you. If you
choose to authorized use or disclosure, you can later revoke that authorization
by notifying us in writing of your decision.
Right to Access and or Amend Your Records:
In most cases, you have the right to look at or get a copy of medical information
that we use to make decisions about your care, when you submit a written
request. If you request copies, we may charge a fee for the cost of copying,
mailing, or other related supplies. If we deny your request to review or obtain a
copy, you may submit a written request for a review of that decision.
If you believe that information in your record is incorrect or that important
information is missing, you have the right to request that we correct the records,
by submitting a request in writing that provides your reason for requesting the
amendment. We could deny your request to amend a record if the information
is not maintained by us; or if we determine that your record is accurate. You
may submit a written statement of disagreement with a decision by us not to
amend a record.
Right to an Accounting:
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 healthcare operations, circumstances in which you have
specifically authorized such disclosure, and certain other exceptions.
To request this list of disclosures, indicate the relevant period, which must be
after April 14, 2003, but in no event for more than at least six years. You must
submit your request in writing to our office listed at the top of this page.
Right to Request Restrictions:
You may request, in writing, that we not use or disclose medical information about you for
treatment, payment or healthcare operations or to persons involved in your care except when
specifically authorized by you, when required by law, or in an emergency. We will consider
your request and work to accommodate it when possible, but we are not legally required to
accept it. We will inform you of our decision on your request.
All written requests or appeals should be submitted to the office listed at the top of this page.
Requests for Confidential Communication:
You have the right to request that medical information about you be communicated to you in a
confidential manner, such as sending mail to an address other than your home, by notifying us
in writing of the specific way or location for us to communicate with you.
Right to request a paper copy of this Notice:
You may receive a paper copy of this Notice from us upon request, even if you have agreed to
receive this notice electronically.
Changes to this Notice:
We may change out policies at any time. Changes will apply to medical information we already
hold, as well as new information after the change occurs. Before we make a significant change
in our policies, we will change our notice and post the new notice in waiting areas, exam
rooms, and on our website at www.ultimate-therapy.com. You can receive a copy of the
current notice at any time. The effective date is listed at the end. Copies of the current notice
will be available each time you come to our facility for treatment. You will be asked to
acknowledge in writing your receipt of this notice.
Complaints:
If you are concerned that your privacy rights may have been violated, or you
disagree with a decision we made about access to your records, you may
contact our office listed at the top of this page.
If you are not satisfied with our response, you may send a written complaint to
the U.S. Department of Health and Human Services Office of Civil Rights:
DHHS, Office of Civil Rights
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201
Under no circumstances will you be penalized or retaliated against for filing a
complaint.
By way of my signature, I provide Ultimate Therapy with my authorization and consent to use
and disclosed my protected health care information for the purposes of treatment, payment
and health care operations as described in the Privacy Notice
________________________________________________
Patient’s Name (print)
________________________________________________
Patient’s Signature
Date
________________________________________________
Authorized Facility Signature
Date
Important Company Policies
We strive to provide you the best personalized care available. To make this possible we adhere to a set of
very important polices. Please read them carefully, and indicate your agreement by signing at the bottom of
the page.
Late Policy
We greatly appreciate you allowing us to provide you with the best physical therapy possible. We want to
continue to be able to do this. Our therapists and staff know your time is important and we hope you
understand the value of our time. We want to be able to provide every patient with the one on one attention
they require. Arriving late for any service may require us to shorten the length of service, change the
therapist or reschedule for another day.
24 Hour Advance Notice Fee
If you wish to change or cancel an appointment we require a minimum 24-hour advance notice. Anything
less will result in a $15 fee charged to your account. Keep in mind this fee is not the responsibility of your
insurance company, it will be an out of pocket expense. It costs money to make appointments available to
you. Whether you attend or not we still accrue the expenses (for staff wages, rent, etc.). We don’t charge
you the actual cost of your appointment but rather a mere $15 fee. We do NOT make money with this
charge; it’s only to act as a deterrent from making last minute changes. Advance notice allows someone
else (who needs it) time to reserve it in place of you. Please be courteous and responsible. Thank you.
No Shows
Please be courteous to our staff and other clients schedules. If you fail to show for an appointment 2 times
without contacting Ultimate Therapy with a valid excuse, all future appointments will be removed and a
$25 fee charged to your account for each no-show appointment. You may re-schedule appointments on a
“first come first serve basis.” After 3 no-show appointments you will no longer be permitted to schedule
any appointments in the future. If a situation arises and you know you will not be able to make your
appointment please contact the office at any hour and leave a message, the phone has 24 hour voicemail
and we will receive the message at the beginning of the next business day.
Cellular Phones
Cell phones must be shut off or silent. We realize emergencies may arise and therefore allow you to carry
your cell phone during your session, however, please be courteous and set to silent mode or turn off.
Children
Children requiring supervision are not allowed to attend sessions with you. If your child does not require
supervision and is capable of waiting for you quietly then you may bring them. If any disturbance is caused
to other patients or staff members you may be asked to terminate your session early and tend to your child.
Payment
“It is unlawful to routinely avoid paying your co-pay, deductible or coinsurance payments.” Failure to
comply places you in violation of the following laws: Federal False Claims Act, Federal Anti-Kickback
Statute, Federal Insurance Fraud Laws, and State Insurance Fraud Laws. Failure to comply may result in
civil money penalties(CMP) in accordance with the new provision section 1128A(a)(5) of the Health
Insurance Portability and Accountability Act of 1996 [section 231(h) of HIPPA].
Signature
Date ____/____/_______
Initial Intake Form
Name:_____________________________________________Date of Birth:____/____/______
Referring Physician:_____________________________________________________________
Family Physician: □Same □Other_________________________________________________________________
Date of next follow up with your physician: ____/____/______
GENERAL HEALTH STATUS
Please rate your health:
□Excellent □Good
□Fair
□Poor
□Other:___________________
MEDICAL HISTORY (Have you ever had or do you currently have any of the following?)
□Asthma
□Diabetes
□Severe or frequent headaches
□Shortness of breath/Chest Pain □Infectious Disease
□Vision or hearing difficulty
□Coronary Artery Disease
□Cancer
□Numbness or tingling
□Pacemaker
□Lymph Nodes Removed
□Dizziness or fainting
□High Blood Pressure
□Chemo
□Weight Loss/Energy Loss
□Heart Attack/Heart Surgery
□Radiation
□Hernia
□Blood Clot
□Arthritis
□Epilepsy/Seizures
□Stroke/TIA
□Osteoperosis
□Thyroid □Hyper □Hypo
□Allergies
□Sleeping difficulties
□Incontinence
□Pins or Metal Implants
□Latex Allergies
□Bowel or Bladder problems
□Joint Replacement
□Weakness
□Neck Injury/Pain
□Shoulder Injury/Pain
□Back Injury/Pain
□Multiple Sclerosis
□Elbow Injury/Pain
□Leg/Ankle/Foot Injury/Pain
□Parkinson’s
□Other:_______________________________________________________________________
CURRENT MEDICATIONS
Please include all prescription, over-the-counter, herbals, vitamin/mineral/dietary [nutritional] supplements. List the name of the drug, dosage, frequency and how it is taken in the appropriate column.
Name
Dosage
Frequency
Route (Oral, SubQ, etc.)
Therapist Initials____________ Date:_______/_______/_________
Name:_____________________________________________Date of Birth:____/____/______
Are you allergic to any medications that you know of? □No
□Yes, please list__________________
_____________________________________________________________________________
_____________________________________________________________________________
CURRENT CONDITIONS
Have you had 2 or more falls in the past year? □No
□Yes
Have you had a fall within the past year resulting in an injury? □No
□Yes, describe_________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Have you ever had surgery?
□No
□Yes, please describe and include dates (if you have a list
please give to receptionist to make a copy)_____________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Describe the problem(s) for which you seek physical therapy:_______________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
What do you hope to gain from physical therapy?_________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
SOCIAL HISTORY
With whom do you live?
□Alone
□Parents
□Spouse/Significant other
□Other:__________________________________
□Spouse/Significant other and children □Group Setting
□Children Only
□Personal care attendant
Employment
□Working full-time
□Homemaker
□Working part-time
□Student
□Currently not working due to condition □Retired
□Unemployed
□Occupation______________________ □Right Handed
□Left Handed
Living Environment
Does your house have?
Where do you live?
□Stairs, no railing
□Private Home
□Stairs, with railing
□Condo
□Ramps
□Apartment
□Elevator
□Trailer
□Uneven Terrain
□Other:________________________
Do you use?
□Cane
□Walker
□Maunal Wheelchair
□Motorized Wheelchair
□Glasses
□Hearing Aide
□Other:__________________________________
Therapist Initials____________ Date:_______/_______/_________
Name:_____________________________________________Date of Birth:____/____/______
PAIN DRAWING
Please be sure to fill this out extremely accurately. Mark the area on your body where you feel the
described sensation(s). Use the appropriate symbols, mark areas of radiating pain, and include all
affected areas. You may draw on the face as well.
Dull/Achy Pain= D
Numbness= N
Stiffness= F
Sharp Pain= P
Tingling= T
Throbbing= B
Please circle the number that best describes your pain. Use the chart below to help gage your answers.
Current Pain: 0
Pain at Best:
0
Pain at Worst: 0
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
7
7
7
8
8
8
9
9
9
10
10
10
Does your pain awaken you at night? □No □Yes How long do you sleep before waking with pain?_____
_____________________________________________________________________________
Do you have days or periods of time when you are completely pain free? □Yes □No
When did these problems begin?_____________________________________________________
Was the onset gradual? □Yes □No
If there was an injury, describe the injury:_____________________________________________
How is your current condition progressing overall? □Improving □Staying the same □Getting worse
What makes the problem(s) better? □Heat □Ice □Rest □Medication □Other:____________
Are you able to continue your usual recreational activities? □Yes □No, explain:________________
_____________________________________________________________________________
What activities increase your symptoms?______________________________________________
Therapist Initials____________ Date:_______/_______/_________
Instructions: Please circle
the level of difficulty you
have for each activity
today.
Able to do Able to do Able to do Able to do Unable to
Not
without
with little
with
with much
do
Applicable
any
difficulty moderate difficulty
difficulty
difficulty
1. Laying Flat
1
2
3
4
5
9
2. Rolling Over
1
2
3
4
5
9
3. Moving-lying to sitting
1
2
3
4
5
9
4. Sitting
1
2
3
4
5
9
5. Squatting
1
2
3
4
5
9
6. Bending/Stooping
1
2
3
4
5
9
7. Balancing
1
2
3
4
5
9
8. Kneeling
1
2
3
4
5
9
9. Walking-short distances
1
2
3
4
5
9
10.Walking-Long distances
1
2
3
4
5
9
11. Walking outdoors
1
2
3
4
5
9
12. Climbing Stairs
1
2
3
4
5
9
13. Hopping
1
2
3
4
5
9
14. Jumping
1
2
3
4
5
9
15. Running
1
2
3
4
5
9
16. Pushing
1
2
3
4
5
9
17. Pulling
1
2
3
4
5
9
18. Reaching
1
2
3
4
5
9
19. Grasping
1
2
3
4
5
9
20. Lifting
1
2
3
4
5
9
21. Carrying
1
2
3
4
5
9
22. Thinking about all of the activities you would like to do, please mark an “X” at the point on the line
that best describes your overall level of difficulty with these activities today.
I have extreme difficulty
I have no difficulty
23. From the list above, choose 3 activities you would most like to be able to do without any difficulty
(for example, if you would like to be able to climb stairs, kneel and hop without any difficulty, you would
choose: 1. 12 , 2. 8 , 3. 13 ).
1._____, 2._____, 3._____
Printed Name:_______________________________________Date of Birth:____/____/______
Therapist Initials____________ Date:_______/_______/_________
Name:_____________________________________________Date of Birth:____/____/______
Please list:
Number of pregnancies_____
Number of Vaginal Deliveries_____
Number of c-sections_____
Was your delivery difficult?
□ Yes
□ No
If yes, how?__________________________
_____________________________________________________________________________
Are you currently pregnant?
□ Yes
□ No
Menopause onset date if applicable:____/____/______
How many bladder infections have you had in the past year? ________________________________
Do you currently have a bladder infection?
Have you expirienced any vaginal dryness?
□ Yes
□ Yes
□ No
□ No
Bladder leakage frequency: □ Never
□Only with strong cough or sneeze □ Only premenstrual
□ Constant ____ # per month/week/day (circle appropriate response)
Severity of leakage: □ No leakage □Few drops
Protection worn: □ None
□ Pantishields
□ Other:________
□Wets underwear
□ Minipads
□ Wets outerwear
□ Maxipad
□ Poise Pad
Leakage caused or increased by:
□ Vigorous activity
□ Light activity
□ Changing positions (sit to stand)
□ Walking to the toilet
□ Intercourse or sexual activity
□ Other:__________
Position or activity with leakage:
□ Lying down
□ Sitting
□ Standing
□ Other:_________________
How long can you delay the need to urinate? □ Not at all
□ 31-60min
□ 1-2 min.
□ Hours
Rate a feeling of “falling out” or pelvic heaviness/pressure:
□ None
□ With standing
□ With evertion
□ At the end of the day
□ Other:_______________
Fliud Intake (one glass=8oz)
□ Strong urge to go
□ 3-10min.
□ 11-30min.
□ Only with menstruation
□Constant
____ glasses per day ____# of caffeinated per day
____# of alcoholic per day
Rate your feelings as to the severity of this problem from 0-10 eith 10 being the worst
0_______________________________________________________10
Therapist Initials____________ Date:_______/_______/_________
Rate the following statement as it applies to you today.
My bladder is controlling my life.
0_______________________________________________________10
Bladder Habits
How often do you urinate during the day? _______# of times
How often do you urinate after going to bed? _______# of times
Do you take your time to go to the toilet and empty your baldder?
Can you stop the flow of urine when on the toilet?
□ Yes
□ Yes
□ No
□ No
Name:_____________________________________________Date of Birth:____/____/______
Is the volume of urine passed usually:
□Large
□Average
Do you have the sensation that you need to go to the toilet?
Do you strain to pass urine?
□ Yes
□Small
□ Yes
□Very Small
□ No
□ No
Do you empty your bladder frequently, before you experience the urge to pass urine?
Do you have the feeling your bladder is still full after urinating?
Do you have a slow or hesitant urinary stream
□ Yes
□ Yes
□ Yes
□ No
□ No
□ No
Do you have “triggers” that make you feel like you can’t wait to go to the toilet? (running water, etc.)
□ Yes
□ No If yes, please list________________________________________________________
Bowel Habits
Frequency of bowel movements _____Per day _____Per week
Consistency of stool: □Loose
□Normal
Do you have a history of constipation?
Do you currently strain to go?
□ Yes
Do you ever ignore the urge to defecate?
□ Yes
□Hard
□ No
□ No
□ Yes
□ No
Do you have trouble making it to the toilet on time when you have the urge to go?
□ Yes
□ No
By signing below you are acknowledging all information above is accurate and complete to the best of your
knowledge.
Patient Signature:____________________________________________________________Date:____/____/_______
Therapist Initials____________ Date:_______/_______/_________
General Consent for Evaluation and Treatment
I acknowledge and understand that I have been referred to Ultimate Therapy for evaluation and treatment of Pelvic Floor Dysfunction. I understand that to evaluate my condition it may be necessary, initially and periodically, to have my physical therapist perform an internal pelvic floor muscle exam to
assess strength, range of motion, scar mobility and muscle length. Such evaluation and treatment may
include, but not be limited to, the following: observation, palpation, use of vaginal cones, vaginal or rectal sensors for biofeedback and/or electrical stimulation, exercise, internal soft tissue mobilization, education, instruction and neuromuscular techniques of the perineal area. Treatment may also include joint
mobilization, modalities such as ultrasound and electrical stimulation, iontophoresis, etc.
I understand that no guarantees have been or can be provided regarding the success of therapy. I hereby
request and consents to the evaluation and treatment to be provided by the physical therapists and physical therapy assistants of Ultimate Therapy.
Patient Name:________________________________________________________________________
Patient Signature:_______________________________________________Date:____/____/_______
Provider Signature: _____________________________________________Date:____/____/_______
TAHNK YOU!