Fillable PATIENT INFORMATION AND CONSENT FORM

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PATIENT INFORMATION AND CONSENT FORM

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Revised January 2021
PATIENT INFORMATION AND CONSENT FORM
CONSENT FOR CARE AND TREATMENT: I hereby agree and give my consent to Foothills Sports Medicine Physical
Therapy to furnish appropriate rehabilitative care and treatment, as considered necessary and in the best interest in order
to attend to the physical condition. I understand that the benefits and risks to all interventions will be explained and that
the patient holds the final judgment in such matters.
If under 18, Parent/Guardian: _______________________________________________________________________
Relationship to Patient: ______________________________ Parent/Guardian Date of Birth: ______________________
MEMBER DIRECT PAYMENT NOTIFICATION: Arizona state constitution permits you to pay a healthcare provider for
health care services directly. If you have any active health insurance coverage, please review the provider’s policies
regarding payment before you make any arrangements to pay directly. By signing below, I agree to have my physical
therapy claims submitted to the medical insurance carrier that I have supplied.
AUTHORIZATION TO PAY: I hereby authorize insurance payment directly to Foothills Sports Medicine Physical Therapy,
Billing Department, 15410 S. Mountain Pkwy. Suite 112, Phoenix, AZ 85044 for medical services rendered. I understand
that I am financially responsible for the charges not covered by my insurance. In the event of default, I promise to pay
collection costs and reasonable fees as may be required to obtain collection of this account.
ATTENDANCE AGREEMENT: Due to the nature of physical therapy, your progress and full recovery are dependent on
both our experienced physical therapists, and your active participation and commitment to your appointments. If you need
to cancel your appointment, please contact Foothills Sports Medicine at least one day prior to your appointment. If you call
to cancel your appointment on the same day as your appointment or if you do not show, a $25.00 cancellation fee will be
assessed.
WORKERS’ COMPENSATION PATIENTS: We are required to inform your Workers’ Compensation Adjuster and/or
Rehabilitation Manager of all missed or canceled appointments. It is also required that all missed visits be rescheduled.
PHOTOGRAPHY/VIDEOGRAPHY AGREEMENT: I understand that in order to protect the confidentiality of our patients,
there can be no filming, going “live” via social media or taking pictures of my treatment, or that of other patients, without
prior authorization from the Clinic Director.
AUTHORIZATION TO COMMUNICATE ELECTRONICALLY: I understand that authorized personnel (including my
physical therapist) from Foothills Sports Medicine Physical Therapy may communicate with me regarding scheduling/
appointments, the treatment provided, home exercise programs, and educational/informative content as it relates to my
condition. I understand that my protected health information (PHI) will not be communicated electronically. I understand
that I have the opportunity to opt-out of future communications at any time using the “unsubscribe” option on any
communication via text or email
Would you like to receive appointment reminders: Text Message Email
By my signature below, I certify that I have read, understand, and fully agree to each of the statements in this document:
Printed Name: __________________________________________________________ Date: _____________________
Patient/Guardian Signature: ________________________________________________ Date: _____________________
Symbols to Use
Aching: Δ Δ Δ Burning: X X X
Stabbing: / / / Numbness: = = =
Pins & Needles:  Radiates: 
0 1 2 3 456789 10
NO PAIN WORST POSSIBLE PAIN
Patient Name:
Date:
Gender:
Male Female
Referring Physician:
Return Visit Date:
Body Part: Date of Surgery:
Date of Injury:
Occupation:
Work Status:
FT PT
Unemployed
Hobbies:
Prior Treatment:
What is the nature of the current injury?
Work Related
Chronic/Reoccurring Fall MVA
Recreational
Lift or Carry Insidious Surgery
What is your pain rating in the last 24 hours? 0-10 Numeric Pain Rating Scale
Please use the diagram provided to mark where your symptoms are currently.
My symptoms are made better by:
My symptoms are made worse by:
My symptoms are:
Constant Intermittent Chronic New
Are your work or activities of daily living limited?
Yes Partial No
In addition to this paperwork, you will complete a functional outcomes
scale.
PATIENT MEDICAL HISTORY FORM
Revised January 2021
Height:
Weight:
How often do you exercise more than 20 minutes per day?
1x/wk 2x/wk 3x/wk 4x/wk
PATIENT MEDICAL HISTORY FORM (CONTINUED)
5x/wk 6x/wk 7x/wk
Do you smoke?
Yes No
List any recent Diagnostics (Xray, MRI, CT Scan, EEG, EMG, Injections):
Do you have any allergies to latex, cold, heat or medications? If yes:
Yes No
Are you on any medications?
Please see attached list provided by the patient.
Are you on any blood thinners?
INR:
Yes No
Past Medical History
Have you recently noted any of the following? (check all that apply)
Changes in Bowel or Bladder
Constipation
Difficulty Swallowing
Dizziness/Lightheaded
Fainting
Fatigue
Fever/Sweats/Chills
Hearburn/Indigestion
Incontinence
Muscle Weakness
Nausea/Vomiting
Numbness/Tingling
Pain that wakes you at night
Rapid Heart Rate/Palpitations
Recent Onset of Headaches
Shortness of Breath
Unexplained Weight gain/loss
Unexplained Cough
Visual Changes
What is your goal for physical therapy?
Patient/Guardian Signature:
Date:
The above information I have provided is complete, true and correct to the best of my knowledge.
Revised January 2021
Have you had Home Health Care or a stay with an Inpatient Facility in the last 30 days? If so, please state where:
Have you been discharged? What was the date you were discharged from care?
Yes No
Stroke/CVA/TIA
TB/HIV/Hepatitis A,B,C
Thyroid Condition
Vascular/Circulation Problems/
Blood Clots
Visual or Hearing Impairments
Osteoporosis
Have you ever been diagnosed with any of the following? (check all that apply)
Anemia
Asthma
Back Pain (Degenerative,
Stenosis, Herniation)
Bladder/Urinary/Kidney
Disease
Bone/Joint infections
Cancer (any)
Chest Pain or Angina
Chronic Headaches
Congestive Heart Failure/Heart
Attack
Depression/Anxiety/Panic
Disorders
Diabetes Type I/Type II
GI Disease (Liver, Ulcer,
Hernia, Reflex, Gall Bladder)
High/Low Blood Pressure
Lung Disease/COPD/ARDS
Neurological Disease
(MS, Parkinson's)
Osteoarthritis/Rheumatoid
Arthritis
Pneumonia
Seizures or Epilepsy
Have you fallen in the last year?
Yes No
If yes, how many times?
Did you sustain an injury when you fell, and if so, please describe:
Under what circumstances did you fall?
(e.g. location, using assistive device, transferring, etc.)
Prior surgeries. Please describe:
Revised January 2021
NOTICE OF PATIENT INFORMATION PRACTICES
This notice describes how medical information about you may be used or disclosed and how you can
get access to information. Please review it carefully.
FOOTHILLS SPORTS MEDICINE PHYSICAL THERAPY’S LEGAL DUTY
Foothills Sports Medicine Physical Therapy is required by law to protect the privacy of your personal health information,
provide this notice about our information practices, and follow these practices that are described herein.
USES AND DISCLOSURES OF HEALTH INFORMATION
Foothills Sports Medicine Physical Therapy uses your personal health information primarily for treatment; obtaining
payment of treatment; conducting internal administrative activities, and evaluating the quality of care that we provide. For
example, Foothills Sports Medicine Physical Therapy may use your personal health information to contact you to provide
appointment reminders, or information about treatment alternatives or other health related benefits that could be of
interest to you.
Foothills Sports Medicine Physical Therapy may also use or disclose your personal health information without prior
authorization for public health purposes, for auditing purposes, for research studies and for emergencies. We also provide
information when required by law.
In any other situation, Foothills Sports Medicine Physical Therapy’s policy is to obtain your written authorization before
disclosing your personal health information. If you provide us with a written authorization to release your information for
any reason, you may later revoke that authorization through a written statement to stop future disclosures at any time.
Foothills Sports Medicine Physical Therapy may change its policy at any time. When changes are made, a new Notice of
Information Practices will be posted in the clinic and will be provided to you on your next visit. You may also request an
updated copy of our Notice of Information Practices at any time.
PATIENT’S INDIVIDUAL RIGHTS
You have the right to review or obtain a copy of your personal health information at any time. You have the right to
request that we correct any inaccurate information or incomplete information in your records. You also have the right to
request a list of instances where we have disclosed your personal health information for reasons other than treatment,
payment or other related administrative purposes.
You may also request in writing that we not use or disclose your personal health information for treatment, payment and
administrative purposes except when specifically authorized by you, when required by law or in emergency
circumstances. Foothills Sports Medicine Physical Therapy will consider all such requests on a case by case basis, but
the practice is not legally required to accept them.
CONCERNS AND COMPLAINTS
If you are concerned that Foothills Sports Medicine Physical Therapy may have violated your privacy rights or if you
disagree with any decisions we have made regarding access or disclosure of your personal health information, please
contact the person(s) listed below. You will not be retaliated against for filing a complaint.
Compliance Department Department of Health and Human Services
15410 South Mountain Parkway, Suite 107 Mail, fax, email, or OCR Complaint Portal
Phoenix, AZ 85044 www.hhs.gov/ocr/hipaa/
888-402-7091
Revised January 2021
PATIENT INFORMATION ACKNOWLEDGEMENT FORM
I have read and fully understand Foothills Sports Medicine Physical Therapy’s Notice of Information Practices.
I understand that Foothills Sports Medicine Physical Therapy may use or disclose my personal health information
for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any
administrative operations related to treatment or payment.
I understand that I have the right to restrict how my personal health information is used and disclosed for
treatment, payment, and administrative operations if I notify the practice.
I also understand that Foothills Sports Medicine Physical Therapy will consider requests for restriction on a case
by case basis.
I hereby consent to the use and disclosure of my personal health information for purposes as noted in Foothills
Sports Medicine Physical Therapy’s Notice of Information Practices.
I understand that I retain the right to revoke this consent by notifying the practice in writing at any time.
Printed Name: Date:
Patient/Guardian Signature: Date:
DESIGNATED INDIVIDUALS AUTHORIZATION FORM
I hereby authorize one or all of the designated parties listed below to request and receive the release of any protected
health information regarding my treatment, payment or administrative operations related to treatment and payment. I
understand that the identity of designated parties must be verified before the release of any information.
Authorized Designees:
Name: Relationship: Phone:
Name: Relationship: Phone:
Name: Relationship: Phone:
Name: Relationship: Phone:
Printed Name: Date:
Patient/Guardian Signature: Date:
How did you hear of Foothills Sports Medicine Physical Therapy?
Drive by location/signage Friend/Family/Patient Magazine Print Ad
Email or Text Google Search/Website
Referred by physician
Employee Referred High School ATC/Coach Returning Patient
FAST Insurance Company/Employer Sports Club
Free Injury Assessment Local Event
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Completed 7 May 2021

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