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    Patient Data Sheet

    Uploaded by

    JJ Lawley
    This document collects patient information for orthopaedic physical therapy services. It requests the patient's name, address, contact information, insurance details, medical history including current medications, height, weight, and pregnancy status. It also asks for an emergency contact and details on the patient's reason for visit such as the location and date of injury, surgery, and doctor appointments. Finally, it includes an authorization for treatment and information release that requires the patient's signature.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Patient Data Sheet

    Uploaded by

    JJ Lawley
    796 views1 page
    This document collects patient information for orthopaedic physical therapy services. It requests the patient's name, address, contact information, insurance details, medical history including current medications, height, weight, and pregnancy status. It also asks for an emergency contact and details on the patient's reason for visit such as the location and date of injury, surgery, and doctor appointments. Finally, it includes an authorization for treatment and information release that requires the patient's signature.

    Original Description:

    Initial Examination Data Sheet

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    This document collects patient information for orthopaedic physical therapy services. It requests the patient's name, address, contact information, insurance details, medical history including current medications, height, weight, and pregnancy status. It also asks for an emergency contact and details on the patient's reason for visit such as the location and date of injury, surgery, and doctor appointments. Finally, it includes an authorization for treatment and information release that requires the patient's signature.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    796 views1 page

    Patient Data Sheet

    Uploaded by

    JJ Lawley
    This document collects patient information for orthopaedic physical therapy services. It requests the patient's name, address, contact information, insurance details, medical history including current medications, height, weight, and pregnancy status. It also asks for an emergency contact and details on the patient's reason for visit such as the location and date of injury, surgery, and doctor appointments. Finally, it includes an authorization for treatment and information release that requires the patient's signature.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Orthopaedic Physical Therapy Services

    Patient Information
    Last Name First Name MI Date of Birth Soc. Sec. #

    Home Address City State Zip Home phone

    Marital Status Have you been treated here before? If yes, when? Cell phone

    Employer Name Title/Position

    Work Address City Zip Work Phone

    Current Medications:

    Insurance Name Ins. Adjuster/Contact Ins. Phone #

    Height Weight
    Do you have a pacemaker? YES or NO Are you pregnant? YES or NO

    History of smoking? If yes, how long? What is your primary goal for physical therapy?

    Emergency Contact Information


    Last Name First Name

    Address City State Zip

    Home Phone Work Phone Relationship

    Reason For Today's Visit


    Is this injury/condition related to your...
    Other:
    Job YES or NO Car YES or NO Home YES or NO
    Location of injury Date of injury Date of surgery

    Doctor Last Doctor's Visit Next Doctor's Visit

    Attorney Information (Name, Address, Phone#)

    Authorization of Treatment and Information Release


    I further authorize OPTS to release any informationto my Doctor and /or insurance carrier.
    Signature: Printed Name Date

    Parent/Guardian Signature: Printed Parent/Guardian Name: Date

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