Exercise Based Rehabilitation Form

    Patient Intake Form Excercise Based Rehabilitation

    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.

    Patient Information











    SDM


    FemaleMale







    Home Cell Email Work Mail



    Informed Consent to Evaluate / Treat

    By my signature, which appears below, I hereby grant my permission for and request that I be evaluated, andtreated by the physical therapist and/or kinesiotherapist, according to the plan of care developed by the physical therapist and/or kinesiotherapist 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 there exists the likelihood of changes in the treatment program as my condition changes and I hereby grant my permission for all modifications and changes to the treatment program deemed necessary by the therapist(s).

    The procedures and or modalities to be used have been explained to me and I have had the opportunity to ask any questions I had, and acknowledge that I have received answers that are satisfactory to me. I understand that the success of this, or any other medical treatment program depends on my involvement and cooperation with the program including regular attendance at all treatment sessions and conscientious follow through with any home exercises or procedures which may be 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 agreed to all statements made above and that my participation in this physical and or/ occupational therapy treatment program is fully voluntary.


    Patient Signature:
    Hold down left-click on your mouse and drag the cursor over the white box to draw your signature.

    Authorization to Disclose Health Information

    Automatically includes your Doctor, your spouse (if applicable) and the insurance company.




    Evaluation(s)
    Progress Notes
    Most recent history and physical
    Most recent discharge summary
    Entire Record
    Other


    Signature of Patient or Legal Representative:
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    Billing Agreement

    Sessions will be made by appointment at your convenience and the availability of the therapist. Sessions are based on a 50-minute hour. A refund may be given only with the written consent of Just Be Fit, Inc. under the following circumstances:

    • A patient relocates to another city or location out side the counties of Cook, Lake or Du Page Illinois.
    • The Medical condition a patient suffers from makes it impossible to continue with their therapist. In this case, a physician’s written notification is required.
    • Sessions which remain unused for a period of one (1) year after the date of purchase will not be honored.
    # OF SESSIONS PRICE PER SESSION TOTAL COST
    1 $105.00 $105.00
    5 $95.00 $475.00
    10 $90.00 $900.00
    20 $85.00 $1700.00


    YesNo


    YesNo

    I have read, understand and accept these policies as they are related to my rehabilitation package called (Exercise Based Rehabilitation.)

    Cancellation / Missed Appointment Policy

    Please be aware that if you need to cancel your therapy appointment a 24 hour notice is required. We appreciate as much advance notice as possible; therefore calls made later than 24 hours prior to your scheduled appointment date and time will be billed to you personally, the cost of a missed appointment ( your EBR package price ) , if you do not provide at least 24-hours notice of a cancellation. Also, if you miss THREE consecutive scheduled therapy appointments without calling to cancel or reschedule your appointment you will be discharged immediately from our Exercised Based Rehabilitation Program. This policy will be enforced after your initial therapy appointment.

    I agree to pay the fees outlined in this policy.

    Initials:*

    Medical History

    Have you ever had, or do you currently have, any of the following? Please check all that apply.


    Bronchitis

    Asthma

    Aneurism

    Anemia

    Alcohol Abuse Problems

    Chronic Obstructive Pulmonary Disease

    Cerebral Palsy

    Coronary Artery Disease/Heart Disease

    Diabetes Type I, Type II

    Emphysema

    Fibromyalgia

    Gout

    Hearing Loss

    Hemorrhoids

    High Blood Pressure / Hypertension

    High Triglycerides

    Hypoglycemia

    Kidney Disease

    Lung Disease

    Muscular Dystrophy

    Osteoporosis

    Paralysis

    Spina Bifida

    TMJ

    Tumors

    Varicose Veins

    Allergies

    Arthritis (Osteo/Rhuematoid/AS)

    Angina

    Back/Spinal Injury

    Cancer

    Cerebral Vascular Accident/Stroke

    Coronary Vascular Disease

    Circulatory Problems

    Embolism

    Epilepsy

    Gastroinestinal/Stomach Problems

    Head Injury

    Heart Attack

    Hernia

    High Cholesterol

    Hyperglycemia

    Crohn's Disease

    Joint Problems (Knee/Shoulder/Hip/Back)

    Low Blood Pressure

    Multiple Sclerosis

    Nervous/Emotional Tension

    Parkinson's Disease

    Poliomyelitis

    Spinal Cord Injury

    Thyroid Problems

    TBI


    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 or Migraines


    Muscle Pain at Rest


    Muscle 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


    Wound That Does Not Heal


    Other Problems





    YesNo


    NoYes






    YesNo

    WOMEN'S HEALTH


    YesNo



    PremenopausalPostmenopausalMenopausal


    Interview


    *If your visit is related to an injury, check the appropriate response in the box below. If it is not related to an injury, skip this section.


    Car AccidentWork InjurySports InjuryFallOther


    HomeWorkSchoolOther


    YesNo






    RightLeftBothNA

    Check each characteristic that best describes your problem:

    Quality
    Sharp
    Throbbing
    Aching
    Burning
    Cramping

    Duration
    Infrequent
    Constant
    Hourly
    Daily
    Weekly

    Context
    Worsening
    Recurrent
    More Frequent

    Symptom Aggravation
    Activity
    Positive Change
    Repetitive Motion
    Fatigue
    Other

    Severity
    Mild
    Moderate
    Severe

    Timing
    After Activity
    Walking
    Running
    Stairs
    Squatting
    Pivoting
    Overhead Use
    Throw
    Life
    Other

    Symptom Relief
    Rest
    Heat
    Cold
    Elevation
    Brace
    Injection
    Medication
    Physical Therapy
    Other



    YesNo


    YesNo


    YesNo


    YesNo


    YesNo






    Signature:
    Hold down left-click on your mouse and drag the cursor over the white box to draw your signature.

    We appreciate your courtesy and thank you for your cooperation. Just Be Fit, Inc looks forward to providing our Physical Therapy services to you.
    Should you have any questions concerning our professional services or office procedures, please ask.

    Sincerely,
    Just Be Fit, Inc Management

    Notice of Health Information Practices

    This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
    Understanding Your Health Record/Information
    Each time you visit a hospital, physician or other healthcare provider a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment and a plan for future care or treatment. This information often referred to as your health medical record serves as a:

    • Basis for planning your care and treatment
    • Means of communication among may health professionals who contribute to your care
    • Legal document describing the care you received
    • Means by which you or a third-party payer can verify that services billed were actually provided
    • A tool in educating health professionals
    • A source of data for medical research
    • A source of information for public health officials charged with improving the health of the nation
    • A source of data for facility planning and marketing
    • A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve

    Understanding what is in your record and how your health information is used helps you to:

    • Ensure its accuracy
    • Better understand who, what, when and why others may access your health information
    • Make more informed decisions when authorizing disclosure to others

    Your Health Information Rights
    Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to:

    • Request a restriction on certain uses and disclosures or your information as provided by 45 CFR 164.522
    • Obtain a paper copy of the notice of information practices upon request
    • Inspect and copy your health record as provided for in CFR 164.525
    • Amend your health record as provided in 45 CFR 164.528
    • Obtain as accounting of disclosures of your health information as provided in 45 CFR 164.528
    • Request communication of your health information by alternative means or at alternative locations
    • Revoke your authorization to use or disclose health information except to the extent that action has already been taken

    Our Responsibilities
    This organization is required to:

    • Maintain the privacy of your health information
    • Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
    • Abide by the terms of this notice
    • Notify you if we are unable to agree to a requested restriction
    • Accommodate reasonable requests you may have to communicate health information by alternative or at alternative locations

    We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you’ve supplied us.

    We will not disclose your health information without your authorization, except as described in this notice.

    For more information or to Report a Problem
    If you have questions and would like additional information, you may contact Just Be Fit, Inc. at (847) 444-1348.

    If you believe your privacy rights have been violated, you can file a complaint with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.

    Examples of Disclosures for Treatment, Payment and Health Operations

    We will use your health information for treatment.
    For example: Information obtained by your physical therapist will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of your physical therapist. Your therapist will then record the actions he/she took and their observations. In that way the physician will know how you are responding to treatment.
    We will also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you’re discharged from therapy.

    We will use your health information for payment
    For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures and supplies used.
    We will use your health information for regular health operations.
    For example: Members of the medical staff, the corporate compliance officer, or other members of our physical therapy staff may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

    Business Associates:
    There are some services provided in our organization through contacts with business associates. Examples include our billing service. When these services are contracted, we may disclose your health information to our business associate so that the can perform the job we’ve asked them to do. To protect your health information, however, we require the business associate to appropriately safeguard your information.

    Communication with family:
    Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment relates to your care.

    Research:
    We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

    Marketing:
    We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

    Workers Compensation:
    We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

    Public Health:
    As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

    Law Enforcement:
    We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.
    Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.
    Effective Date: 3-20-13