PHYSICAL THERAPY HEALTH HISTORY. Name. Address: Street Apt City State Zip. Cell Phone: address:

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PHYSICAL THERAPY HEALTH HISTORY CLIENT INFORMATION

Name:_____________________________________________________________________________________________

First Middle Last

Address:___________________________________________________________________________________________

Street Apt City State Zip

Home Phone: ___________________ Cell Phone:_____________________ Email address:______________________ Date of Birth: ________________Gender: ________ Marital Status:_______ Spouse’s Name: _______________________

EMPLOYMENT INFORMATION

¨ Full Time ¨ Part Time ¨ Retired ¨ Unemployed ¨ Student

Occupation: __________________________________ Employer: _____________________________________ Employer’s Address:__________________________________________________________________________________

Street Address City State Zip Phone

HEALTH CARE INFORMATION

Primary Care Physician:_______________________________________________________________________________

Name Specialty Phone

__________________________________________________________________________________________________

Street Suite City State Zip

Referring Physician:__________________________________________________________________________________

Name Specialty Phone

__________________________________________________________________________________________________

Street Suite City State Zip

Who may we thank for referring you? _________________________________________________________________ In case of an emergency, please call: _________________________________________________________________

Name Relationship

__________________________________________________________________________________________________

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Kristen M. Reynolds, PT, DPT, PMA-CPT

HEALTH HISTORY

Do you see any of the following professionals for examination or treatment? Doctor, including naturopath or osteopath

Physical Therapist Chiropractor Podiatrist Acupuncturist

Body Worker (i.e. massage therapist, rolfer) Nutritionist

Psychologist, Psychiatrist, or other mental health practitioner Other:

What is the reason for your visit?_______________________________________________________________________ __________________________________________________________________________________________________ When did your symptom(s) begin? ______________________________________________________________________ Have you recently experienced any of the following symptoms? Please “X” appropriate boxes:

¨ Numbness

¨ Tingling

¨ Dizziness

¨ Night Pain

¨ Fever, chills, or sweats

¨ Unusual fatigue or drowsiness

¨ Unexplained weight loss

¨ Nausea, vomiting, loss of appetite

¨ Visual disturbance

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Please place an “X” for any locations of pain, shade areas of numbness, and denote tingling with “---”

Rate your lowest level of pain in the past week, with 0/10 indicating “no pain” and 10/10 indicating “worst pain possible” that is in need of emergency medical attention.

0 1 2 3 4 5 6 7 8 9 10 Rate your highest level of pain in the past week.

0 1 2 3 4 5 6 7 8 9 10 Rate your present level of pain.

0 1 2 3 4 5 6 7 8 9 10 Circle one of the following to indicate the frequency of your symptoms.

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Describe the quality of your pain by placing an “X” next to any words that apply:

Achy Sharp

Burning Shooting

Dull Throbbing

Electric Other:

List any imaging or diagnostic tests you have had for this condition: ____________________________________________ __________________________________________________________________________________________________ Please list all prescribed, over-the-counter medications, nutritional, or herbal supplements taken in the past three months: __________________________________________________________________________________________________ __________________________________________________________________________________________________ What particular motions or activities are most affected by your symptoms?

Note any significant injuries or surgeries for which you have been treated (i.e. sprains, dislocations, fractures, tendinitis), including date and involved side (L or R):

Head Neck

Thoracic Spine Ribs

Shoulder Arm

Forearm Wrist

Hand Lumbar Spine

Sacroiliac Joint Pelvis

Hip Thigh

Knee Lower Leg

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Please place an “X” in the appropriate box if you have been diagnosed with any of the following by a medical professional:

ACL Injury Gastric Reflux

AIDS/HIV Glaucoma

Adhesive Capsulitis/Frozen Shoulder Headaches/Migraines

Allergies Hemophilia (slow healing)

Angina (chest pain) Hypertension (high blood pressure)

Anemia High Cholesterol

Anxiety/Panic Attacks Kidney Disease/Stones Asthma, hay fever, respiratory problems Lyme Disease

Cancer Multiple Sclerosis

Cardiovascular Disease Osteoarthritis

Carpal Tunnel Syndrome Osteoporosis or osteopenia Chemical Dependency (alcohol or drugs) Plantarfascitis

Chronic Fatigue Syndrome Rheumatoid Arthritis Cirrhosis/Liver Disease Rotator Cuff Syndrome Degenerative Disc/Joint Disease Scoliosis

Depression Spinal Stenosis

Diabetes Stroke

Eating Disorder (anorexia or bulimia) Thoracic Outlet Syndrome

Epilepsy/Seizures Thyroid Disorder

Facet Joint Syndrome Other:

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Please provide details for any of the diagnoses including approximate date and surgical intervention:

__________________________________________________________________________________________________ __________________________________________________________________________________________________

WOMEN’S HEALTH HISTORY

Are you currently pregnant? YES NO # Vaginal Deliveries ___________ # C-Sections _________________ Have you given birth? YES NO Date of Last Delivery ___________

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)

1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? YES NO

2. Do you feel pain in your chest when you do physical activity? YES NO

3. In the past month, have you had chest pain when you were not doing physical activity? YES NO 4. Do you lose your balance because of dizziness or do you ever lose consciousness? YES NO

5. Do you have a bone or joint problem that could be made worse by a change in your physical activity? YES NO 6. Is your doctor currently prescribing any drugs (e.g. water pills) for your blood pressure or heart condition? YES NO 7. Do you know of any other reason why you should not do physical activity? YES NO

If you answered yes to one or more of these questions, then you should talk with your physician to receive a physical activity clearance before you start this physical activity program. This physical activity clearance is valid for a maximum of 12 months and becomes invalid if your condition changes so that you would answer YES to any of the seven questions. I have read the above information and certify it to be true and hereby authorize Kristen M. Reynolds, PT, DPT, PMA-CPT to do whatever is necessary for the care and management of this complaint.

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CONSENT TO TREAT

I, ______________________________________, authorize Kristen Reynolds, PT, DPT, PMA-CPT to perform any therapeutic procedure or treatment that is consistent with my health status, diagnosis, injury, illness, or condition. This consent is intended as a waiver of liability for such treatment excepting acts of negligence. I acknowledge that from time to time, I will receive manual, or “hands-on,” assistance during physicaltherapy visits and/or Pilates sessions in a manner that is safe and appropriate and I am comfortable with this aspect of this program. I understand that I will be given the

opportunity to ask questions regarding my treatment, and that my physical therapist will be available to answer my questions and I can terminate an activity at any time if I do so desire.

Acknowledging that some physical therapy interventions and Pilates exercises are contraindicated under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep Kristen Reynolds, PT, DPT, PMA-CPT updated to any changes in my medical profile and understand that there shall be no liability on her part should I forget to do so.

I understand that a medical evaluation is advisable before beginning any program of physical conditioning, exercise, or manual assistance from an allied health and wellness professional. I have or will continue to keep Kristen Reynolds, PT, DPT, PMA-CPT informed of any physical condition or disability that would prevent or limit my participation her services. I acknowledge that although the program I participate in may have substantial physical benefits, Kristen Reynolds, PT, DPT, PMA-CPT, k pilates rehab, nor OMBE can provide sessions that serve as a substitute for medical diagnosis or treatment when such attention is needed.

I give permission for Kristen Reynolds, PT, DPT, PMA-CPT to disclose my health care information to other professionals for the purpose of treatment, payment or pertinent operations. On occasion, it may be necessary to seek consultation regarding my condition from other physicians or health care providers who will need to treatment from.

I assume all risks of participation in services offered by Kristen Reynolds, PT, DPT, PMA-CPT. I have read, fully understand and completed this form and agreement. Any questions that I had were answered to my full satisfaction. I have signed it freely and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by law and agree that if any portion of this agreement is held to be invalid, I understand that I have given up substantial rights by signing below.

Name _____________________________________________________________________________________________ Signature __________________________________________________________________________________________ Signature of Parent/Guardian of Minor ___________________________________________________________________ Date ______________________________

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OMBE Privacy Policies Notice

This notice describes how your medical information may be used and disclosed, how you can access this information, and how your privacy is being protected at OMBE. The privacy of your medical information is important to us and we are committed to protecting your medical records. We create a record of the care and services you receive at OMBE. We need this record to provide you with quality care and to comply with certain legal requirements. In order to maintain the level of service that you expect from a health care office, we may need to share limited personal medical and financial information. This notice also describes your rights and certain duties we have regarding the use and disclosure of medical information.

How OMBE May Use or Disclose Your Health Information

This medical practice collects health information about you and stores it in a paper chart and on a computer. Your medical records are the property of this medical practice, but the information in the medical record belongs to you. The law permits us to use or disclose your health information for the following purposes:

Treatment: We use medical information about you to provide your health care. We disclose medical information to our employees and others who are involved in providing the care you need. For example, we may share your medical

information with other physicians or other health care providers who will provide services that we do not provide. Or we may share this information with a physician who will need to treat you, or a laboratory that performs a test.

Payment: We use and disclose medical information about you to obtain payment for the services we provide. For example, we give your health plan the information it requires before it will pay us. We may also disclose information to other health care providers to assist them in obtaining payment for services they have provided to you.

Health Care Operations: We may use and disclose medical information about you to operate this integrative health care practice. For example, we may use and disclose this information to review and improve the quality of care we provide, or the competence and qualifications of our staff. We may use and disclose this information to get your health plan to authorize services or referrals. We may also use and disclose this information as necessary for medical reviews, legal services, and audits, and including fraud detection and compliance programs. We may also share your medical information with our "business associates", such as our billing service, that perform administrative services for us. We have a written contract with each of these business associates that contains terms requiring them to protect the confidentiality of your medical information. We may also share your information with other health care providers, health care clearinghouses or health plans that have a relationship with you, when they request this information to help them with provide service to you

Appointment Reminders: We may use and disclose medical information to contact and remind you about appointments. If you are not available, we may deliver this information to an email address, a voicemail inbox, answering machine, or leave a message with the person answering your home phone.

Notification and Communication with Family: We may disclose your health information to notify a family member, your personal representative, or another person responsible for your care about your location, your general condition in the event you are sick or injured. We may also disclose information to someone who is involved with your care or helps pay for your care. If you are able and available to agree or object, we will give you the opportunity to object prior to making these

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disclosures, although we may disclose this information despite your objection, if we believe it is necessary to respond to emergency circumstances. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.

Marketing: We may contact you to give you information about products or services related to your treatment, case management or care coordination, or to direct or recommend other treatments or health-related benefits and services that may be of interest to you.

Required by Law: We will limit our use and disclosure of your health information to relevant law requirements. When the law requires us to report abuse, neglect, or domestic violence, respond to judicial or administrative proceedings, or respond to law enforcement officials, we will further comply with the requirement set forth below concerning those activities.

Public Health & Safety: We may and are sometimes required by law to disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury, or disability; reporting child, elder, or dependent adult abuse or neglect; and reporting domestic violence. When we report suspected elder or dependent adult abuse or domestic violence, we will inform you or your personal representative promptly unless in our best professional judgment, we believe the notification would place you at risk of serious harm, or would require informing a personal representative we believe is responsible for the abuse or harm.

Health Oversight Activities: We may, and are sometimes required by law to disclose your health information to health oversight agencies during the course of audits, investigations, inspections, licensure and other proceedings, subject to the limitations imposed by federal law.

Judicial and Administrative Proceedings: We may, and are sometimes required by law, to disclose your health information in the course of any administrative or judicial proceeding to the extent expressly authorized by a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request or other lawful process if reasonable efforts have been made to notify you of the request and you have not objected, or if your objections have been resolved by a court or administrative order.

Worker's Compensation: We may disclose your health information as necessary to comply with worker's compensation laws. For example, to the extent your care is covered by workers' compensation, we will make periodic reports to your employer about your condition. We are also required by law to report cases of occupational injury or occupational illness to the employer or workers' compensation insurer.

Change of Ownership: In the event that this medical practice is sold or merged with another organization, your health information/record will become the property of the new owner, although you will maintain the right to request that copies of your health information be transferred to another physician or medical group.

When OMBE May Not Use or Disclose Your Health Information: Except in the cases above as described in this Privacy Policies Notice, OMBE will not use or disclose health information that identifies you without your written authorization. If you do authorize this medical practice to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

Right to Request Special Privacy Protections: You have the right to request restrictions on certain uses and disclosures of your health information, by a written request specifying what information you want to limit in our use or disclosure. We reserve the right to accept or reject your request, and will notify you of our decision.

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Right to Request Confidential Communications: You have the right to request that you receive your health information in a specific way or at a specific location. For example, you may ask that we send information to a particular e-mail account or to your work address. We will comply with all reasonable communication requests submitted in writing.

Right to Inspect and Copy: You have the right to inspect and copy your health information with limited exceptions. To access your medical information, you must submit a written request detailing what information you want access to and whether you want to inspect it or get a copy of it. We will charge a reasonable fee, as allowed by federal law. We may deny your request under limited circumstances. If we deny your request to access your child's records because we believe allowing access could cause substantial harm to your child, you will have a right to appeal our decision.

Right to Amend or Supplement: You have a right to request that we amend your health information that you believe is incorrect or incomplete. You must make a request to amend in writing, and include the reasons you believe the information is inaccurate or incomplete. We are not required to change your health information, and will provide you with information about this OMBE's denial and how you can disagree with the denial. We may deny your request if we do not have the information, if we did not create the information, if you would not be permitted to inspect or copy the information at issue, or if the information is accurate and complete as is. You also have the right to request that we add to your record a statement of up to 250 words concerning any statement or item you believe to be incomplete or incorrect.

Right to an Accounting of Disclosures: You have a right to receive an accounting of disclosures of your health information made by this office, except that this office does not have to account for the disclosures provided to you or pursuant to your written authorization, or as described in the Treatment, Payment, Health Care Operations, Notification and Communication with Family paragraphs. Additionally, this office does not have to account for disclosures otherwise permitted or authorized by law, or the disclosures to a health oversight agency or law enforcement official to the extent this office has received notice from that agency or official that providing this accounting would be likely to impede their activities.

Changes to This Notice of Privacy Policies: We reserve the right to amend this Privacy Policies Notice at any time in the future. Until such amendment is made, we are required by law to comply with this Notice. After an amendment is made, the revised Privacy Policies Notice will apply to all protected health information that we maintain, regardless of when it was created or received.

Complaints: Complaints about this Privacy Policies Notice or how this medical practice handles your health information should be directed to our Privacy Officer, Jessica Molleur, Lic.Ac., DNBAO. If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint without the risk of penalization to: Department of Health and Human Services, Office of Civil Rights, Hubert H. Humphrey Bldg., 200 Independence Avenue, S.W., Room 509F HHH Building, Washington, DC 20201.

Request a Copy of This Privacy Policies Notice: You have the right to request a paper copy of this Privacy Policy Notice, even if you have previously requested its receipt by e-mail. If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact Jessica L. Molleur, Lic.Ac., DNBAO. If you have questions about our privacy policies, please contact Jessica Molleur, Lic.Ac., DNBAO during regular business hours.

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Privacy Policies Acknowledgement

I have received, read, and understood the Privacy Policies Notice of OMBE. I understand how this integrative health care office may use or disclose my health information. I understand when this integrative health care office may not use or disclose my health information. I understand my health information rights and understand that the office reserves the right to change the Privacy Policies Notice. I also understand how to place a complaint regarding this Notice and have also been provided the opportunity to review and question the privacy policies of the integrative health care office.

_____________________________________________________________ __________________________

Signature of Patient or Authorized Representative Date

24-HOUR CANCELLATION POLICY (Please initial below.)

I understand that if I schedule an appointmentat OMBE, I will be responsible for the full charge of the session should I need to cancel and do not provide 24-HR notice prior to the scheduled appointment.____________