Exercised Based Rehabilitation Form Exercise-Based Rehabilitation Form Save time and fill out your intake form before your appointment! Please fill out the form below. Items marked with an asterisk are required when submitting. 1. Patient Information Date* Last Name* First Name* M.I. Home Address* City* State* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingWashington DC Zip* Date of Birth* Gender MaleFemale Marital Status MarriedSingle Cell Phone* Home Phone Work Phone Email Address* Emergency Contact Name and Phone #* How would you like to be contacted? Home Cell Work E-mail Referring Physician* Primary Care Physician* 2. Informed Consent to Evaluate / Treat By signing below, I hereby grant permission for and request to be evaluated and treated by (including but not limited to) by a physical therapist, occupational therapist, kinesiotherapist and/or other qualified therapy providers in accordance with a plan of care developed by the therapist(s) and prescribed by my physician in consultation with the therapist(s). I understand that the purpose of this program is to enhance my recovery from an illness, injury or surgery. It has been explained to me that changes may be made to my treatment program as my condition changes. I hereby give my permission for any modifications or changes to the treatment plan that are deemed necessary by the therapist(s). The procedures and/or treatment modalities to be used have been explained to me, and I have had the opportunity to ask any questions, I acknowledge that I have received satisfactory answers to all of my questions. I understand that the success of this or any other medical treatment program depends on my active participation and cooperation, including regular attendance at all treatment sessions and diligent follow-through with any home exercises or procedures prescribed by the therapist(s). I understand what is expected of me as a patient and agree to cooperate to the best of my ability. I hereby attest that I have read and agree to all of the statements above and that my participation in this therapy treatment is voluntary. Signature of Patient or Legal Representative: Hold down left-click on your mouse and drag the cursor over the white box to draw your signature. Date 3. Authorization to Disclose Health Information (This authorization includes your physician, your spouse (if applicable) and your insurance company.) 1. Authorization I authorize the use and/or disclosure of the above-named individual's protected health information as described below. The following individual(s) or organization(s) are authorized to make this disclosure. 2. Information to Be Used or Disclosed The type and amount of health information to be used or disclosed includes (check all that apply and include dates when appropriate): Evaluations Progress Notes Most recent history and physical Most recent discharge summary Entire medical record Other Other (Including disclosure to my spouse, child, sibling, friend or any other(s) named here to receive information regarding my medical records.): 3. Sensitive Information I understand that my health record may contain information related to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information related to behavioral or mental health services, and treatment for alcohol and/or substance use disorders. 4. Recipient of Information This information may be disclosed to and used by the following individual(s) or organization(s): Name(s): Address: 5. Right to Revoke I understand that I have the right to revoke this authorization at any time by submitting a written request to the Healthcare Management Office. I understand that any revocation will not apply to information already disclosed in response to this authorization. I further understand that revocation does not apply to my insurance company when the law provides the insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event, or condition: If no expiration is specified, this authorization will expire twelve (12) months from the date of signature. 6. Voluntary Authorization I understand that authorizing the disclosure of my health information is voluntary. I may refuse to sign this authorization and understand that I am not required to sign this form in order to receive treatment. I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided under 45 CFR §164.524. I understand that once the information is disclosed, it may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations. Signature of Patient or Legal Representative: Hold down left-click on your mouse and drag the cursor over the white box to draw your signature. Date 4. Billing Agreement Therapy sessions are scheduled by appointment, based on patient convenience and therapist availability. Sessions are provided in 50-minute increments. Refund Policy Refunds will be issued only in written consent to and from Just Be Fit, Inc. and only under the following circumstances: The patient permanently relocates to another city or location outside Cook, Lake, or Du Page counties. The patient's medical condition changes such that continuation of therapy is no longer medically appropriate. In such cases, written notification from a physician is required. Unused sessions remaining one (1) year from the date of purchase will not be honored or refunded. Exercise Based Rehabilitation Packages # OF SESSIONS PRICE PER SESSION TOTAL COST 1 $125.00 $125.00 5 $115.00 $575.00 10 $105.00 $1,050.00 15 $95.00 $1,425.00 I authorize continued payment to be charged to my credit card once my package has been fully used. YesNo I authorize Just Be Fit, Inc. to charge my credit card for modalities or services not included in my Exercise-Based Rehabilitation package. YesNo If you answer "Yes" to either authorization above; please provide your credit card information below or present your card to the front desk for secure processing. I have read, understand, and agree to the policies outlined above as they relate to my participation in the Exercise-Based Rehabilitation (cash-pay) program. Patient Signature: Hold down left-click on your mouse and drag the cursor over the white box to draw your signature. Date 5. Cancellation / Missed Appointment Policy A minimum of 24 hours' notice is required to cancel or reschedule a therapy appointment. Appointments canceled with less than 24 hours' notice, or missed appointments ("no-shows"), will be charged the full session fee, which may be deducted from the patient's Exercise-Based Rehabilitation package or billed directly to the patient. Patients who miss three (3) consecutive scheduled appointments without proper notice may be discharged from the Exercise-Based Rehabilitation Program. This policy will be enforced after the patient's initial therapy appointment. I agree to pay the fees outlined in this policy. Initials:* 6. Medical History Please check any conditions you have had in the past or are currently being treated for: Alcohol Abuse Problems Allergies Anemia Arthritis (Osteo/Rheumatoid/AS) Aneurism Angina Asthma Back/Spinal Injury Bronchitis Cancer Chronic Obstructive Pulmonary Disease Cerebral Vascular Accident/Stroke Cerebral Palsy Coronary Vascular Disease Coronary Artery Disease/Heart Disease Circulatory Problems Diabetes Type I, Type II Embolism Emphysema Epilepsy Fibromyalgia Gastrointestinal/Stomach Problems Gout Head Injury Hearing Loss Heart Attack Hemorrhoids Hernia High Blood Pressure / Hypertension High Cholesterol High Triglycerides Hyperglycemia Hypoglycemia Crohn's Disease Kidney Disease Joint Problems (Knee/Shoulder/Hip/Back) Lung Disease Low Blood Pressure Muscular Dystrophy Multiple Sclerosis Osteoporosis Nervous/Emotional Tension Paralysis Parkinson's Disease Spina Bifida Poliomyelitis TMJ Spinal Cord Injury Tumors Thyroid Problems Varicose Veins TBI Please provide details for any selections made above (including dates, treatment, or current status): Have you recently experienced any of the following? Please check and provide a description to all those that apply: Back/Leg Pain Blurred or Double Vision Bowel/Bladder Changes Brain Fog Calf Pain With Exercise Change in Speech Pattern Chest Pain or Pressure Constant Pain Unrelieved by Rest or Movement Difficulty Keeping Balance Difficulty Sleeping Difficulty Swallowing Dizziness, Fainting, or Blackouts Falls Fatigue Irregular Heartbeat Headaches/Migraines Muscular Pain at Rest Muscular Pain with Exertion Numbness or Tingling in Arms, Hands or Legs Ringing in Ears Shortness of Breath Stroke Swollen, Stiff, or Painful Joints Tremors Unexplained Weight Gain Unexplained Weight Loss Unusual Skin Coloration Unusual Weakness or Fatigue A Wound That Does Not Heal Other Current Height Current Weight Have you undergone a complete medical exam within the past twelve (12) months? YesNo Please indicate the date of your most recent exam (regardless of time): Please list all medications you are taking: Name / Reason / Amount / Frequency / Side Effects Please list any homeopathic remedies, herbal supplements, vitamins, minerals or other products you are currently taking for the treatment of any condition or deficiency. Include THC and/or CBD products if applicable: Name / Reason / Amount / Frequency / Side Effects Please describe any surgeries and/or hospitalizations: Procedure / Reasons / Date Please list any assistive devices you currently use (e.g., cane, brace, walker, crutches, etc.), indicate whether the device was prescribed by a healthcare provider, and describe the reason for use: Please describe any past or ongoing treatments by a healthcare provider, including but not limited to, physician, physical therapist, chiropractor, massage therapist, acupuncturist, etc: Has a healthcare provider ever advised you not to exercise? YesNo If yes, please explain: WOMEN'S HEALTH: 1. Are you pregnant? YesNo 2. When was your last menstrual cycle? 3. Are you currently: PremenopausalPostmenopausalMenopausal 4. List any symptoms that accompany your menstrual cycle: 7. Interview Reason for today's visit: Injury-Related Information *Complete this section below, only if today's visit is related to an injury. Date of Onset / Injury Symptoms Location of Symptoms The injury is due to: Car Accident Sports Injury Fall Other The injury occurred at: Home Work School Other Is legal action / litigation pending due to this injury? YesNo If yes, please provide more information: Workers' Compensation Disclosure Just Be Fit, Inc. does not accept Workers' Compensation cases. Please indicate whether your condition is related to work-related injury or occupational exposure: YesNo I understand that Just Be Fit, Inc. does not accept Workers' Compensation cases. If my condition is work-related and I fail to disclose this information, I acknowledge that I am solely responsible for payment of all services rendered and that payment is required at the time of service. I understand that I will be responsible for providing any Workers' Compensation or employer-related documentation and for handling all matters directly with any third party. Just Be Fit, Inc. is not responsible for communicating with, billing, or seeking payment from Workers' Compensation carriers, employers, or any other third party. All services are provided on a cash-pay basis, and third-party payment will not be accepted under any circumstances. Symptom Characteristics Please check all that apply. Quality Sharp Throbbing Aching Burning Cramping Duration/Frequency Infrequent Constant Hourly Daily Weekly Clinical Pattern Worsening Recurrent More Frequent Aggravating Factors Activity Position Change Repetitive Motion Fatigue Other Severity Mild Moderate Severe Timing/Functional Triggers After Activity Walking Running Stairs Squatting Pivoting Overhead Use Throw Lift Other Relieving Factors Rest Heat Cold Elevation Brace Injection Medication Physical Therapy Other Treatment History Please describe any treatment you have received for this condition and your response: Previous History Have you experienced a problem in this area before? YesNo If yes, please describe the prior condition and treatment: Diagnostic Testing Have you had any diagnostic tests related to this condition? YesNo If yes, please list the test(s) and location performed: Do you have a copy of the results? YesNo If yes, did you provide them today? YesNo Has a physician or other healthcare provider recommended surgery? YesNo If yes, please provide more information: Name of previous treating provider(s), if applicable (optional): Pain & Functional Status Current pain level (0-10 scale): Current functional limitations: Activities affected by pain or dysfunction: Activity level prior to onset or injury: Goals What are your goals for therapy? 8. Patient Acknowledgment I certify that the information provided above is accurate and complete to the best of my knowledge. I understand that this information will be used solely for the purpose of planning and providing physical therapy services, in accordance with applicable federal and Illinois state laws, including HIPAA. Signature: Hold down left-click on your mouse and drag the cursor over the white box to draw your signature. Date Practice Statement Thank you for choosing Just Be Fit, Inc. We appreciate your cooperation and look forward to providing therapy services tailored to your needs. If you have any questions regarding our services, policies, or procedures, please ask a member of our staff. Sincerely, Just Be Fit, Inc. Management
