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Initial Evaluation Form
Email address *
Full name, address, and date of birth: *
(Optional) What is your gender and what pronouns do you use?
Please provide a brief description of your current injury/condition? *
What activities make the pain from your injury/condition worse? What makes it feel better? *
Have you had a related surgery? *
If you had a related surgery, what was the date?
Are you currently employed? If so, what is your profession? *
MEDICAL HISTORY Have you ever experienced or been diagnosed with (check all that apply) *
Required
If you checked any of the above, please describe
Please list all medications that you are presently taking *
Please list any allergies *
If you are having pain, please rate the intensity of your pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain possible. What is the WORST your pain gets? *
What is your pain TODAY? *
What is the BEST (ie lowest) your pain gets? *
Do you participate in any sports, exercise programs, or activities on a regular basis? If so, what and how often? *
In case of emergency, whom should we contact? Please give NAME, RELATIONSHIP TO YOU, PHONE NUMBER? *
In the last 2-14 days, have you had any of the following COVID-19 symptoms: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea? *
Within the last 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with anyone who has tested positive for COVID-19 or symptoms consistent with COVID-19? *
Have you travelled within or outside of the US in the past 14 days? *
By typing my full name, I attest that the above information is true and that I will not attend in-person sessions if I develop COVID-19 symptoms or have been exposed to someone with COVID-19. *
How did you find out about Outback Physical Therapy? *
I understand that I am a patient of Outback Physical Therapy. If I opt to receive online treatment, my treatment will be via the Zoom secure and HIPPA compliant online platform. I understand that online sessions include guided self-massage instruction, exercise prescription and guidance, activity specific evaluation, and assessment of my movement patterns, balance, and range of motion. Manual or "hands on" treatment is not part of the online sessions. *
I understand that I am requesting rehabilitative treatment and care from Outback Physical Therapy. I understand that I have the right to ask and have any questions answered prior to receiving any treatment; including any risks or alternatives to the treatment plan. By signing this agreement, I consent to have Outback Physical Therapy provide treatment and care as prescribed by my physician and/or recommended by my therapist. I understand, acknowledge and affirm that such rehabilitation and related services may involve bodily contact, touching and/or direct contact of sensitive nature. *
I know and agree that Outback Physical Therapy is not responsible for loss or damage to personal valuables. *
I hereby release, discharge and acquit Outback Physical Therapy, its agents, representatives, affiliates, employees, or assigns, of and from any and all liability, claim, demand, damage, cause of action, or loss of any kind arising out of or resulting from my refusal to accept, receive or allow emergency and or medical services, including but not limited to ambulance service, Emergency Medical Technician, physician or urgent care services. *
I hereby assign all benefits directly to and also authorize release of any medical records necessary to facilitate my treatment to process medical claims and as otherwise permitted or required in the Notice of Privacy Practices. I understand fully that in the event my insurance company or financially responsible party does not pay for the service I receive, I will be financially responsible for payment. *
I acknowledge receipt and agree to Outback PT’s notice of privacy practice (can be retrieved at https://www.outbackpt.com/about-us/forms/ ) *
Required
I understand that Outback PT will bill my health insurance company. If payment is denied, I will pay the clinic rates. *
I understand that I may be given home exercise program and home tips to allow me to progress towards my goals. *
CANCELLATION POLICY: We understand that there are times when you must miss an appointment. Please give us at least 24 hours notice, so that we can offer care to another patient on our waitlist. There is a cancellation fee of $40 for no-shows or appointments cancelled with less than 24 hours notice. If you have 3 cancellations with less than 24 hours notice, we will ask that you call for a same day appointment, rather than booking ahead. We thank you for your understanding. *
Entering my full name below serves as my signature that I agree to all aspects of this consent form *
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