PATIENT INFORMATION:

Marital Status Choose OptionSingleMarriedDivorcedWidowedSeparatedPartner / DomesticOther

Contact Information:

Home Address:

Employment:

Employment Status *Full TimePart TimeRetiredNot Employed

Emergency Contacts:

INSURANCE INFORMATION:

Have you had any Home Health? *YesNo

Workers Compensation and/or Personal Injury Protection (Motor Vehicle Accident): (* if applicable):

*  I acknowledge financial responsibility for deductible, copay, coinsurance, or non-covered services

MEDICAL HISTORY & CURRENT CONDITION:

Current Problem / Body Part *

Date Problem Began *DateNot sure

How did it occur? *Gradual onsetSports injuryWork injuryMotor vehicle accidentFallSurgeryOther

Have you had any imaging done for this condition (i.e. MRI, X-Ray, CT)? *YesNo

Do you have a referral / prescription for physical therapy from a provider? *YesNo

What has the pain affected? (check all that apply) MobilitySleepExerciseRelationshipsWorkSocialActivityConcentrationAppetite

Has the patient seen any other specialist for this condition before? *YesNo

Have you had any surgery related and/or unrelated to this condition? *YesNo

Past Medical History High Blood PressureHeart DiseaseStrokeDiabetesCancerOsteoporosisArthritisThyroid DisorderLung ProblemsKidney DiseaseNeurological DisorderDepression / AnxietyBlood ClotsAsthmaCurrently PregnantNoneOther

Are you currently taking medications? *YesNo

Do you have any allergies? *YesNo

ACTIVITY & GOALS:

During the past few months has the patient exhibited any signs of depression? *YesNo

Has the patient recently lost interest or pleasure in his or her enjoyed activities? *YesNo

Current Activity Level SedentaryLightly ActiveModerately ActiveVery Active

Activities limited due to condition

Please indicate any current habits and frequency: (i.e. 4 cigarettes/day)

HIPAA ACKNOWLEDGMENT: (Select one)

I acknowledge that I have read a copy of Axis Physical Therapy’s Notice of Privacy Practices and understand my rights regarding my protected health information (PHI).I request a copy of the HIPAA Notice of Privacy Practices for my records.

CANCELLATION & NO-SHOW POLICY:

Cancellation and No‑Show Policy

It is your responsibility to ensure that you arrive on time for all your treatments as outlined and advised by your physical therapist.

Any notice of cancellation received less than 24 hours before scheduled appointment time is a late cancellation. The first cancellation will not result in a charge. The second late cancellation will result in a $150 fee, which you must pay before treatment continues. Upon a third late cancellation, we reserve the right to terminate care from the clinic.

When a no-show occurs, it will result in a $150 fee. If we do not receive a response within 24 hours of the missed appointment, we reserve the right to cancel all future appointments.

*  I acknowledge and agree to the Cancellation & No‑Show Policy