Therapeutic Evolution Pelvic Rehab Patients Form

Patient Registration

Today's Date*

Date of 1st Visit

Diagnosis/Reason for Treatment

Returning Patient?*

Yes
No

Payment Type

Self Pay
Insurance
Auto
Workers Comp

Patient Name*

First Last

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Gender*

Male
Female

Marital Status*

Single
Married
Divorced

Home Phone*

Work Phone

Cell Phone

Email*

Emergency Contact Name

Emergency Contact Name*

First Last

Relation*

Home Phone

Work Phone

Cell Phone

Physician Information

Referring Physician*

Office Phone

Primary Care Physician*

Office Phone

Have you had physical therapy before?*

Yes
No

When/Where?

Insurance Information

Primary Insurance

Member ID#

Group #

Subscriber Name

First Last

Subscriber Date of Birth

Relationship to Patient

Subscriber Phone

Address

Street Address City State ZIP Code

If different from patient

Secondary Insurance

Member ID#

Group #

Subscribers Name

First Last

Subscribers Date of Birth

Relationship to Patient

Subscriber Phone

Other

How did you hear about us?

If you are a returning patient, what brought you back to us?

Consent to Treatment

I hereby authorize the professional staff at Therapeutic Evolution Physical Therapy to examine and treat me with physical therapy for the injury I have been referred here for or referred myself to.

Patient Signature*

Assignment of Benefits and Release of Medical Information Instruction for Direct Payment to Health Provider

Insurance Company/Companies Name(s)

I hereby instruct the above-named insurance company/companies to pay by check made out to and mailed directly to: Therapeutic Evolution Physical Therapy (Assignee) for professional or medical expenses allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for 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 fees for non-covered services and/or fees, over and above the insurance payment or as required by my insurance policy.

I hereby release Assignee, its officers, agents, employees and any clinical staff associated with my case, from all liability that may arise as a result of disclosure of information to the above-named insurance company(s) or their designated representatives. By signing this Assignment of Benefits and Release of Medical Information I acknowledge the following: I am aware and understand that this authorization will not be used unless the above named insurance company(s) or their designated representatives request records of information for reimbursement purposes; or seek to take action reference payment for treatment services, I agree to participate and assist Assignee or its designated representatives with any appeal process necessary to collect payments for services rendered, I understand that this assignment and authorization is subject to revocation at any time except to the extent that action has been taken in reliance thereof, I understand Assignee is acting in filing for insurance benefits assigned to myself and it can assume no responsibility for guaranteeing payment of any charges from the insurance company(s), I understand a firm contracted by Assignee for billing and collection purposes may do billing, I understand that Assignee is appointed by me to act as my representative and on my behalf in any proceeding that may be necessary to seek payment from my insurance carrier which includes receiving a copy of my insurance plan’s documents, I agree that should an overpayment take place, a refund check will be mailed to the authorized party that is due the overpayment, I agree that Assignee shall be entitled to the full amount of its charges without offset.

HIPAA REGULATIONS

I understand that Therapeutic Evolution Physical Therapy complies with HIPAA and will protect my Protected Health Information (PHI) and will use it as allowable by law in the treatment, billing and collection pertaining to my care until my case is closed and full payment is received. I also authorize the release of any information pertinent to my case to any insurance company, adjuster or attorney for the purpose of securing payment under this policy of insurance or to any Medical Provider associated with my case to effectively treat me. The authorization is in effect until 90 days from the date the last bill is collected.

I have received a copy of the Notice of Information Practices.*

Initial

A photocopy of this Assignment shall be considered effective and valid as the original.*

Initial

Informed Consent for Assessment of Pelvic Floor Dysfunctions

I understand that if I undertake physical therapy for pelvic floor dyfunction, it will be beneficial and necessary for my therapist to perform a muscle assessment of the pelvic floor, initially and periodically to access muscle strength, length, range of motion and scar mobility. Palpation of these muscles is most direct and accessible if done via the vagina and/or anal/rectal canal. Pelvic floor dysfunctions include but are not limited to pelvic pain syndromes, urinary incontinence, fecal incontinence , dyspareunia or pain with intercourse, pain from an episiotomy or scarring, vulvodynia, vestibulitis, constipation, pain with urination or defecation, diffuse gluteal pain, organ prolapse, diffuse lower extremity pain, other similar complications. Evaluation of my condition may include observation, direct muscle palpation, soft tissue mobilization, use of vaginal or rectal sensors for biofeedback and/or electrical stimulation. The benefits and risks of the vaginal/rectal assessment have been explained to me. I understand that if I am uncomfortable with the assessment or treatment procedures AT ANY TIME, I will inform my therapist and the procedure will be discontinued and alternatives will be discussed with me.

Initials*

Treatment procedures for pelvic floor dysfunctions include, without limitation, education, exercise, neuromuscular reeducation using biofeedback, neuromuscular reeducation, electrical stimulation, and several manual techniques including massage, myofascial release, strain counter strain, ischemic pressure, joint and soft tissue mobilization. The therapist will explain these treatment procedures to me and I may choose not to participate with all or part of the treatment plan. Risks/side effects may include: muscle or joint soreness, slight muscle pain, referred discomfort to another part of the body, fatigue, temporary discomfort with defecation, walking or activities of daily living. I understand that no guarantees have been or can be provided to me regarding the success of therapy. I understand the risks, benefits and alternatives of the different treatment procedures. I hereby voluntarily agree to allow my physical therapist to perform both initial and periodic muscle assessments of the pelvic floor via the vagina or anal/rectal canal and to perform muscular treatment techniques of the perineal area.

Initials*

I want to have an additional person (chaperone) in the room during my sessions.*

Yes
No

Initials*

PLEASE NOTE: If you are pregnant, have an infection of any kind, have vaginal dryness, are less than 6 weeks postpartum or post-surgery, have severe pelvic pain, sensitivity to KY Jelly/vaginal creams or latex, please inform the therapist prior to the pelvic floor assessment.

Patient Intake Form

What is your present complaint?

How long have you had this current complaint?

List your past surgeries, injuries, or major medical problems: (be as specific as possible)

Are you currently being seen for any other medical problems? If so, what are they? If so, what are they?

What have your tried to treat this problem before? Was it effective?

What do you do that increases your complaint?

What do you do that decreases your complaint?

Have you had any special tests? (cystoscopy, MRI, CT scan etc.)

Any history of pregnancy?

How many?

Vaginal or C-section?

Vacuum birth/forceps?

Episiotomy?

Epidural?

How old were you when you started to menstruate?

Are/were your cycles regular?

Painful?

How old were you when you first became sexually active?

Any history of abuse?

Any history of falls on the pelvis or tailbone?

Bladder symptoms

Do you lose urine when you:

Check box for yes.

cough
sneeze
laugh
lift
exercise
jump
on the way to the restroom
hear running water

Do you wear leakage protection?

Yes
No

Liner/Mini pad or adult pad?

Yes
No

How many do you use during a typical day?

Have a strong urge to urinate?

Yes
No

Have difficulty starting a stream of urine?

Yes
No

Strain to empty your bladder?

Yes
No

Feel unable to empty your bladder?

Yes
No

Have pain with a full bladder?

Yes
No

Have urgency to urinate?

Yes
No

Urinate more than 7 times per day?

Yes
No

How many during the day?

At Night?

Yes
No

How many glasses of water do you intake per day?

How many glasses of caffeine do you intake per day?

How many alcoholic drinks per day?

Other drinks per day?

Bowel Symptoms

Do you strain to have a bowel movement?

Yes
No

Leak or stain feces?

Yes
No

Include fiber in your diet?

Yes
No

Have diarrhea often?

Yes
No

Take laxatives or use enemas regularly?

Yes
No

Leak gas by accident?

Yes
No

Have pain with bowel movements?

Yes
No

Have a very strong urge to move your bowels?

Yes
No

How often do you move your bowels per day?

How often do you move your bowels per week?

Most common stool consistency?

liquid
soft
firm
pellets
other

Sexual Symptoms

Do you have pain with intercourse?

Pain after sex?

Do you tolerate manual sex?

Oral sex?

Do you need lubricant?

Are you able to climax?

Patient Signatures

Patient Signature

Date

Patient Printed Name

First Last

Parent or Guardian Signature (If under 18)

Parent or Guardian Printed Name

First Last

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Name

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