Rehab 4 Life Physical Therapy Patient Registration Information
Please complete the following information. Print clearly using a pen. Thank you.
Today’s Date: ___________________
Last Name: _______________________ First Name: _____________________ Middle Initial: _______
Preferred Name: ________________ Social Security Number: ______ - ______ - ______
Birthdate: ____ / ____ / ____ Age: ____ Gender: M F Marital Status: Single Married Divorced Widowed
Address: __________________________ City: ___________________ State: _____ Zip Code: ________
Home Phone: __________________ Cell: __________________ Work (alternate): _________________
Email: ___________________ @ _____________ . ________
Do you prefer appointment reminders via text or email? (circle one) Email Text cell phone carrier: _________
Employed? Y
N
If yes, name of Employer: _______________________
How Did You Hear About Rehab 4 Life? __________________ Referring Physician: _________________
Emergency Contact Name ______________________________ Phone ___________________
Relationship to Patient _________________________________
Worker’s Compensation or Personal Injury/Auto Injury Case, Please Complete the Following Information:
Claim Number: ________________________________
Date Claim Was Opened: ______________
Claim Contact Person: ___________________________
Phone: ____________________
Automobile Insurance Company: _____________________________________________________
Automobile Insurance Address: _____________________________ City: _________________ State: _____
Automobile Insurance ID #: _________________________________
Please have proof of both primary and secondary insurance available
Primary Insurance Information:
Secondary Insurance Information:
Insurance Company_________________________
Group #___________________________________
ID #______________________________________
Contact #__________________________________
Insurance Company_________________________
Group #___________________________________
ID #______________________________________
Contact #__________________________________
Getting you back to Work, Sport, Health, Life
History of Present Condition
Patient Name: ______________________
Occupation: _____________________________________
On a scale from 0-10, 0 being no pain, 10 being absolute worst pain, please rate your pain today:
0
1
2
3
4
5
Reason for Visit? __________________________
6
7
8
9
10
Personal Goals for Therapy: ________________________
When did symptoms begin? __________________________________________________________________
(list specific date if possible)
Was the onset/timing of this episode:  Gradual
 Sudden
Any previous episodes? Y
N
Which of the following best describes how injury occurred? (if condition is post-surgical, please indicate as per original injury)
 Unknown
 While Lifting
 Vehicle Accident
 A Fall
 Trauma
 Work Incident
 Dental Appointment
 Degenerative Process
Have you seen a physician? Y
 Sports
 Other (Please Specify) ___________________________________
N Who? ______________________________ When?__________________
Have you had any tests performed? Y
Have you had any X-Ray’s taken? Y
N
Type of test(s) performed? ______________________________
N Results: _______________________________________________
Are you currently on any medication? Y
N (please list)___________________________________________
Have you had any form of treatment prior to today’s visit? Y
N What Kind? _________________________
Since the onset, are your symptoms  Improving  Staying the Same  Worsening
What aggravates your symptoms? (Check all that apply)
 Sitting  Going to/Rising From Sitting  Walking  Up/Down Stairs  Standing  Squatting
 Lying Down  Sleeping  Looking Up Overhead  Sustained Bending  Reaching Overhead
 Reaching in Front of Body  Reaching Behind Back  Reaching Across Body  Coughing/Sneezing
 Taking a Deep Breath  Talking  Chewing  Yawning  Swallowing  Stress
 Repetitive Activity _______________________________________________________________________
 Household Activity ______________________________________________________________________
 Recreation/Sports Including: ______________________________________________________________
What relieves your symptoms? (Check all that apply)
 Nothing  Medication  Wearing Splint/Orthosis  Rest  Cold  Heat  Sitting  Standing
 Walking  Lying Down  Stretching  Exercise  Massage
Getting you back to Work, Sport, Health, Life
Medical History
Patient Name: _______________________
Have you had any falls in the past year? Y
N If yes, how many times? _______  Injured  Uninjured
Are you currently pregnant or trying to get pregnant? Y
Have you had any of the following?
Stroke
Heart Disease or Murmur
High Blood Pressure
Asthma
Diabetes
Epilepsy/Fainting
Impairment of Vision
Impairment of Hearing
Cancer
Drug Allergies
Osteoporosis
Do you smoke tobacco products?
N
Explain
 Present
 Present
 Present
 Present
 Present
 Present
 Present
 Present
 Present
 Present
 Present
 Past
 Past
 Past
 Past
 Past
 Past
 Past
 Past
 Past
 Past
 Past
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
 Present  Past How much per day? _________________________
Have you ever sprained, strained, dislocated or fractured the following?
Head/neck (including concussion) ____________________________________Date________________
Trunk (ribs, vertebrae, sternum) ______________________________________Date________________
Low Back (vertebrae, discs, nerves) ___________________________________Date_______________
Upper Extremity (shoulder, elbow, wrist, arm) ___________________________Date_______________
Lower Extremity (hip, leg, knee, ankle, foot) ____________________________Date_______________
Please list any surgeries that you have had including the date of surgery:
__________________________________________________________________________________________
__________________________________________________________________________________________
Have you had Physical Therapy in the past?  Yes
 No If yes, Where? __________________________
What condition were you being treated for? _____________________________________________________
I certify the above information is accurate and correct to the best of my knowledge. I will notify Rehab 4 Life
immediately should any of this information change.
Patient Signature: _______________________________________
Print Name: ___________________________________________
Date: ___________________
Consent and Authorization for Treatment
Name:____________________________
DOB:________________
Today’s Date:__________________
CONSENT FOR CARE/SERVICES
I hereby consent and authorize Rehab4Life/At Home Therapy Services, its agents and associates to provide care
and treatment to me as explained and agreed upon. A representative of Rehab4Life/At Home Therapy Services
has explained my plan of care to me and all of my questions have been explained to me satisfactorily. I
understand that the treatment plan may change, and, if so, these changes will be discussed with me.
RELEASE OF INFORMATION
I hereby consent/authorize Rehab4Life/At Home Therapy Services to disclose/release information contained in
my clinical record to the healthcare providers, third party payers, utilization review and professional standards
review organizations, regulatory review entities and any other organizations, companies and community
resources that may assist in my cares. All other parties would require my written consent. I consent to having
an electronic capture of any medical information, current insurance card(s) and valid photo ID.
ACCEPTANCE OF SERVICES
I have agreed to receive the following services:
_____ Physical Therapy
_____ Occupational Therapy
____ FCE
LIABILITY FOR PAYMENT
I understand that services provided to me by Rehab4Life/At Home Therapy Services will be billed to the
following:
_____ Medicare
_____ Medicaid
_____ Directly to me or my guarantor
Policy # __________________________
_____ My Insurance company (specify)
____________________________
Policy #_________________________________
_____ Private Pay _______________________________________________________________
ASSIGNMENT OF BENEFITS
I request payment of authorized benefits be made on my behalf to Rehab4Life/At Home Therapy Services. I
understand and agree to pay all deductibles, co-payments and any amounts due after payment of benefits
on my behalf by any and all third party payers, within 30 days of services rendered. Failure to make
payment within 30 days will result in an automatic 1.5% interest charge on account balance, which will
accrue each month until balance is paid in full.
THIS AGREEMENT is applicable only to this current admission to Rehab4Life/At Home Therapy Services.
I understand what I have read and what was explained to me and agree to the terms and conditions stated above.
Additionally, I understand either party may terminate this agreement at any time. I certify that all information
given by me is correct to the best of my knowledge.
____________________________________________________
Patient Signature or Parent/Guardian if patient is a minor
_______________
Date
____________________________________________________
Rehab4Life/At Home Therapy Services Representative
_______________
Date
Rev.10/16