Fillable Patient Information Marital Status: Single Married Divorced Widowed

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Patient Information Marital Status: Single Married Divorced Widowed

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  • 66 check-boxes
  • 139 other fields

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Patient Information
Patient Name: _______________________________________________________________________________________________
Last First Middle
Street Address: ______________________________________________________________________________________________
Street City State Zip
Phone: (H) ____________________________ (W) ______________________________ (C) _______________________________
I authorize Kaizo Health to leave messages on answering services & to send SMS
messages for reminders, surveys, specials, announcements etc.
Birth date:____/____/____
Marital Status: Single Married Divorced Widowed Other
Email: _______________________________________________
I authorize Kaizo Health to send me emails for reminders, e-statements/bills, and informational newsletters.
Employer’s Name _____________________________________
Employer’s Address ___________________________________________________________________________________________
Street City State Zip
Emergency Contact Information
Emergency
Contact:_____________________________________________________________________________________________________
Name Relationship Phone #
I authorize Kaizo Health to leave or give information to spouse, emergency contact or any member of household listed above.
By signing the bottom of this page I authorize that the information provided above is true to the best of my knowledge. I
understand that I may be billed administrative and filing fees for withholding information as it relates to my medical history
and insurance coverage.
Print Name _____ Signature ____________ _ Date ______________
(Parent/Guardian if patient is a minor)
Referral Source and Primary Care Doctor Information
How did you hear about us? ____________________________ Primary Care Physician ____________________________
Health Insurance Information
Is your injury related to an auto accident, worker’s comp accident, or other accident resulting in legal proceedings? YES NO
Primary Health Insurance Name: _____________________________________ Phone #____________________________
Policyholder’s Name (if not self}: _____________________________ Relationship ________________ D.O.B. ____/_____/____
Secondary Health Insurance Name: ___________________________________ Phone #____________________________
Policyholder’s Name (if not self}: _____________________________ Relationship ________________ D.O.B. ____/____/____
If you would like to put a credit card on file check the box and fill in your Credit Card Information
I prefer to be charged automatically on my credit card for any out of pocket cost or balances relating to my care and treatment that
are not covered By my insurance. With the signature at the bottom of the page I authorize Kaizo Health to charge any of these
charges on the credit card listed below. I will present the card at the first visit. To protect my safety the complete credit card
number cannot and will not be kept on file:
VISA MC AMEX DISCOVER LAST 4 DIGITS OF CC#:_
_________ EXP DATE: ____________
Occupation ____________________________________________
Gender: M
ale F
emale
Other
Prefer not to say
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INSURANCE AUTHORIZATION OF TREATMENT, INSURANCE ASSIGNMENT AND RELEASE
I, the undersigned, have insurance coverage with ________________________________ and assign directly to
Kaizo Health / First Choice Physicians LLC t/a Sport & Spine Rehab, Greenstein and Associates DC t/a Metro Sport &
Spine, Sport & Spine Rehab of McLean, Sport & Spine Rehab of Ft. Washington, and/or Sport and Spine Rehab of
Fairfax all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially
responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all
information necessary to secure payment of benefits. I authorize the use of this signature on all my insurance submissions.
FINANCIAL POLICY
1. I am ultimately responsible for full payment for any and all services rendered.
2. I am considered as a SELFPAY patient until I have provided completed insurance forms, and that your office has
qualified and accepted my coverage, otherwise I pay at the time of service.
3. I am responsible for any costs not covered by my insurance and therefore must pay deductibles, copays,
coinsurances and one-time initial $5 medical supply/administrative/processing fee at the time of service.
4. Insurance Benefits quoted by my insurance company are NOT a guarantee of payment or coverage.
5. Sport and Spine Rehab/Kaizo Health makes every attempt to receive authorization of treatment from insurance companies
for treatment received at one of our facilities. However, there may be times when the insurance company does not
provide this authorization in a timely manner. SSR/KH will submit claims as a courtesy to me. If my insurance carrier has
not paid a claim within the terms of the contract within 60 days of submission, SSR/KH will submit an appeal one time. If
the claim is not paid within 30 days of the appeal, I will be responsible for taking an active part in the recovery of my
claim. After 90 days, I will be responsible for the balance and I authorize the use my credit card, if supplied, to be charged
for full payment. If I do not have a card on file I must remit payment in full upon receipt of the bill.
6. In the event I discontinue my plan of care prior to the doctor’s consent, I am responsible for any outstanding balance and the
courtesy of insurance assignment is immediately discontinued.
7. Sport and Spine Rehab/Kaizo Health will attempt to bill me for 90 days via email, mail and phone for any outstanding
balances. If I have not made a payment after 90 days my account may be sent to a collection agency for further action
including potential credit reporting. I agree to reimburse Sport and Spine Rehab/KaizoHealth for the fees of any collection
agency, which may be based on a percentage not to exceed 50% of the debt, and all costs, and expenses, including
reasonable attorney's fees, incurred by Sport and Spine Rehab/Kaizo Health in such collection efforts.
8. I agree that in order for Sport and Spine Rehab to service my account or to collect any amounts I may owe, Sport and Spine
Rehab may contact me by telephone at any telephone number associated with my account. This includes wireless telephone
numbers, which could result in charges to me. Sport and Spine Rehab may also contact me by sending text messages or e-
mails, using any e-mail address I have provided to them. Methods of contact may include using pre-recorded/artificial
voice message and/or use of an automatic dialing device, as applicable. I have read this disclosure and agree that Sport and
Spine Rehab Holdings, LLC or any agency working on behalf of SSR Holdings, LLC may contact me/us as described above.
9. I understand that I can be charged a $25.00 NO SHOW/LATE CANCEL fee for any appointment not rescheduled or
canceled at least 24 hours in advance.
Note: In
formation collected in these forms or in the treatment process may be used in its raw data form (no
mention of patient name) to analyze for research purposes.
By Signin
g below I agree to all statements in the Financial Policy, Insurance Assignment and Insurance
Authorization and Release above.
______________________
____________ __________________________________________ _____________
Patient’s Printed Name Signature of Patient Date
(If patient is a minor, Parent or Guardian signs)
NOTICE OF PRIVACY PRACTICES AND PATIENT’S RIGHTS AND RESPONSIBILITIES
PLEASE CHECK THE BOX, SIGN, AND DATE below to acknowledge receipt of the HIPAA Privacy Practices and Patient
Rights and Responsibilities:
I have read and/or was offered a copy of the Notice of Privacy Practices and Patient Rights and Responsibilities by
Sport and Spine Rehab/Kaizo Health.
______________________
___________ __________________________________________ _____________
Patient’s Printed Name Signature of Patient Date
(If patient is a minor, Parent or Guardian signs)
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CONSENT TO EXAMINATION AND CARE
I hereby authorize Sport and Spine Rehab/Kaizo Health and its licensed doctors and assistants, based on my complaints and the history I have provided,
to undertake an examination and provide an evaluation and treatment plan which may include spinal manipulation and other tests and procedures
considered therapeutically appropriate. I also wish to rely on the Sport and Spine Rehab/Kaizo Health doctors to make those decisions about my care,
based on the facts then known, that they believe are in my best interest.
The nature and purpose of the examination and evaluation, the treatment and the other procedures that may be recommended during the course of my
care have been explained and described to my satisfaction.
By signing below I acknowledge my consent to be examined:
____________________________________ _________________________________________ ______________
Patient’s Printed Name Patient’s Signature (parent/guardian for minor) Date
_________________________________________________________________________________________________________________________
The specifics of the doctor’s recommendation will be further explained during a Report of Findings following your examination and any subsequent
examinations and significant changes in your diagnosis or treatment plan.
Based on current findings, Sport and Spine Rehab/Kaizo Health doctors have discussed my diagnosis and treatment plan, the benefits and expected
improvement with the proposed treatment and the reasonable alternatives to the proposed treatment. They have also explained the cost of my proposed
care (or provided me with a current fee schedule) and to the extent practicable the costs of reasonable alternatives to the proposed treatment.
To aid the understanding of my condition and the reasons for the proposed course of care, Sport and Spine Rehab/Kaizo Health doctors have answered
my questions regarding the planned treatments and course of care that I will receive. Sport and Spine Rehab/Kaizo Health doctors have also explained
that my diagnosis and treatments may change during the course of care and that they will advise me of material changes in my diagnosis and treatment
options and answer any additional questions that I may have at any time.
I have also been advised that although the incidence of complications associated with services is very low, anyone undergoing adjusting or manipulative
procedures should know of rare possible hazards and complications which may be encountered or result during the course of care. These include, but
are not limited to, fractures, disk injuries, strokes, dislocations, sprains, and those which relate to physical aberrations unknown or reasonably
undetectable by the doctor.
I understand and accept that:
1. I have the right to withdraw from or discontinue treatment at any time and that Sport and Spine Rehab/Kaizo Health doctors will advise me of
any material risks in this regard.
2. Neither physical therapy/chiropractic care nor medicine itself is an exact science and that my care may involve the making of judgments
based upon the facts known to the doctor during the course of my care.
3. It is not reasonable to expect the doctor to be able to anticipate or explain all risks and complications
4. An undesirable result does not necessarily indicate an error in judgment or treatment.
5. Sport and Spine Rehab/Kaizo Health does not guarantee results with respect to any course of care or treatment.
6. My care and treatment will not be observed or recorded for any non-therapeutic purpose without my consent.
I have read this Consent (or have had it read to me) and have also had an opportunity to ask questions about the Consent and understand to my
satisfaction the care and treatment I may receive. My signature below acknowledges my consent to the examination, evaluation and proposed course of
care and treatments by Sport and Spine Rehab/Kaizo Health.
__________________________________ _________
Signature of Doctor Date
____________________________
Patient’s Printed Name
Doctor’s Notes:
________________________________________
Patient’s Signature (Parent/Guardian signs for minor)
_____________
Date
Patient counseled by: Discussion _______________________
THE GENERAL ERISA ASSIGNMENT FORM
The ERISA portion of the assignment will allow us to pursue any insurance entity, other than government entities such as Medicare and Medicaid, for
payment of your denied claims in a more effective manner than is allowed under State law and will allow us to pursue these insurance companies for
any ERISA claims procedures violations.
I assign the right to payment for all medical benefits directly to Allen Huffman, D.C. at Sport and Spine Rehab/Kaizo Health (Tax ID#
522044715) in consideration for medical services and supplies provided pursuant to my health insurance plan.
In the event my health insurance plan refuses to pay for provided, medically necessary services, I also assign all my ERISA rights to
Allen Huffman, D.C. at Sport and Spine Rehab/Kaizo Health (Tax ID# 522044715) for a full and fair review of any and all denied claims,
including any penalties that may be assessed against the insurance company for faulty claims processing. This ERISA assignment is in
consideration for the unpaid services provided, in consideration for my insurance plan’s reduced fee schedule, and in consideration for
the continued willingness Allen Huffman, D.C. at Sport and Spine Rehab/Kaizo Health (Tax ID# 522044715) to see patients, including
myself, on an insurance assignment basis. I understand that if my treating doctor prevails in any such payment dispute, I may be liable for
co-payment for the contested services.
I give consent to release medical information to Allen Huffman, D.C. at Sport and Spine Rehab/Kaizo Health (Tax ID# 522044715). I give
consent to Allen Huffman, D.C. at Sport and Spine Rehab/Kaizo Health (Tax ID# 522044715) to release medical information to other
healthcare providers for the purpose of treatment, when necessary for my care. I give consent to Allen Huffman, D.C. at Sport and Spine
Rehab/Kaizo Health (Tax ID# 522044715) to send medical information, as necessary, to my insurance plan.
*ERISA is an acronym for the Employee Retirement Income Security Act. The Employee Retirement Income Security Act includes federal laws
requiring insurance companies to process submitted insurance claims and appealed (denied) insurance claims according to ERISA regulations.
The failure to process submitted insurance claims and appealed (denied) insurance claims according to ERISA regulations may result in fines
charged to the insurance company in amounts up to $110 a day for each infraction.
Patient's Printed Name
Signature of Patient
(If patient is a minor, Parent/Guardian signs
_____________
Date
Kaizo Clinical Research Institute
The Kaizo Clinical Research Institute (formally the Sport and Spine Rehab Clinical Research Foundation) is a
non-profit research organization created by the founders of Sport and Spine Rehab/Kaizo Health. They would
like to invite you to provide permission to include de-identified information about your condition in a larger
research database. It is important you read and understand the information below before you agree to be a
participant. Your relationship with Sport and Spine Rehab/Kaizo Health will not change if you decline.
Part of Kaizo Health and the Kaizo Clinical Research Institute’s goal is to ensure our doctors are providing the
best treatments and maximizing clinical outcomes. Clinical outcomes are pain, disability, and quality of life
measures. This information is collected in the form of a questionnaire at the start and end of your therapy.
The Foundation would like permission to include your information in a study database. The purpose of this
database is to track the outcome measure results of Kaizo Health's treatment programs. Your records will be
assigned a random number instead of using your name. This allows all information to be kept private. Only
members of the research team will have access to the password protected database.
Please ask questions about what you do not understand before agreeing to take part, as this is voluntary. You
may withdraw and stop participating at any time without affecting your care. If at any time you wish to with-
draw your consent please let any member of the research or clinic staff know.
Statement of Consent: I have read the information above. I have had the chance to ask questions and have
them answered. I agree to allow my information to be added to an outcome measures database.
Kaizo Clinical Research Institute
Sport and Spine Rehab Clinical
Research Foundation
_____________________________________ _____________________
Parcipant’s Name Date
______________________________________ _____________________
9300 Livingston Rd
S
uite 100
Fort Washington, MD 20744
Phone: 240-760-0300 x 835
Fax: 301-251-1829
E-mail: jslaski@kaizo-health.com
Parcipant’s Signature Date
_____________________________________ _____________________
Parental/Guardian Signature (under 18) Date
CONSULTATION FORM
Patient Name: ___________________________________________________________ Gender: M F
Current Symptoms (Be specific) ___________________________________________________________________________________________
When did the symptoms first appear? ___ Rate your symptoms on a scale from 0-10 ________________
What makes the symptoms worse or increase? ______________________________________________________________________________
What makes the symptoms better or decrease? _______________
What are the top 1-3 goals to consider your care a success?
1._____________________________________ 2.____________________________________ 3._____________________________________
What will help you be most accountable to your careplan to achieve those goals? __________________________________________________
Have you seen another health care provider for this problem? YES NO If yes, who? ________________________________________
The symptoms are:
constant mild sharp dull achy
frequent moderate burning stiffness swelling
occasional severe numbness tingling other _
Review of Current Symptoms: Do you Currently have any….
YES
Generalized symptoms such as weakness, fatigue, fever, chills, night sweats, fainting, change in sleep pattern, unexplained
weight loss/gain or others? (circle symptom if listed)
Skin problems such as rashes, itching, dryness, sores, changes in skin color, changes in moles, changes in hair, changes in
fingernails, or others? (circle symptom if listed)
Lung problems such as coughing, phlegm, shortness of breath, difficulty breathing, wheezing, congestion, coughing blood, or
others? (circle symptom if listed)
Heart problems such as a murmur, palpitations, rapid heartbeat, extremity swelling, chest pain, cold extremities, high/low blood
pressure, or others? (circle symptom if listed)
Gastrointestinal problems such as stomach pain, nausea/vomiting, diarrhea, gas/bloating, constipation, rectal bleeding,
change in appetite/thirst, change in stools or others? (circle symptom if listed)
Genitourinary problems such as painful urination, blood in urine, frequent urination, incontinence, urgency, change in urine
appearance or others? (circle symptom if listed)
Musculoskeletal problems such as muscle pain, muscle weakness, muscle twitching, joint stiffness, joint pain, joint swelling,
hot joints or others? (circle symptom if listed)
Neurological problems such as numbness, tingling, weakness, paralysis, loss of memory, loss of sensation, difficulty with
coordination, dizziness, difficulty with speech or others? (circle symptom if listed)
Psychiatric problems such as depression, anxiousness, hallucination, drug addiction, suicidal thoughts, difficulty sleeping or
others? (circle symptom if listed)
Eye, nose or throat problems such as blurred vision, double vision, eye pain, hearing loss, ringing in ear, vertigo, sinus
problems, loss of smell, hoarseness, difficulty swallowing or others? (circle symptom if listed)
If you answered Yes to any question above please explain:______________________________________________________________________
______________________________________________________________________________________________________________________
PAST MEDICAL HISTORY
Please check () to indicate if you have had any of the following:
AIDS/H
IV Breast Lump Gonorrhea Liver Disease Shingles
Alcoholism Bulimia Gout Migraines Stroke
Anemia Cancer Heart Disease Multiple Sclerosis Suicide Attempt
Anorexia Diabetes Hepatitis Osteoporosis Thyroid Problems
Appendicitis Drug Abuse Hernia Pacemaker Tuberculosis
Arthritis Emphysema Herpes Polio/Post-Polio Tumors
Asthma Epilepsy High Cholesterol Psychiatric Care Ulcers
Blood Disorders Glaucoma Kidney Disease Rheumatoid Arthritis Venereal Disease
PLEASE LIST ANY MAJOR ILLNESSES, INJURIES, FRACTURES, OR SURGERIES YOU HAVE HAD
ILLNESS, INJURY, FRACTURE, SURGERY
DATE
TREATMENT
Please list any allergies you have: ___ _______
Please list any medications you are currently taking: _______
Please list any vitamins/nutritional supplements you are taking: _______
FAMILY HISTORY
List any diseases that run in your family
BLOOD RELATIVE
MAJOR ILLNESS
Father
Mother
Brother(s)
Sister(s)
Other Relative
SOCIAL HISTORY
Please check () all that apply.
SMOKING EXERCISE ALCOHOL CAFFEINE
Never Smoked Exercise None No Alcohol No Caffeine
Previously Smoked Light Exercise Presently Drink Alcohol Yes Caffeine
Presently Smoke Moderate Exercise # Drinks/Week __________ # Cups/day ________
# Pack/Wk #Years________ Heavy Exercise (Includes beer, wine, liquor) (Includes coffee, tea, soda)
THIS
CONFIDENTIAL HISTORY WILL BE A PART OF YOUR PERMANENT RECORDS
Your Rights
When it comes to your health information, you have certain rights.
This s
ection explains your rights and some of our responsibilities to help
you.
Get an electronic or paper copy of your medical record
You can ask to see or get an electronic or paper copy of your medical
record and other health information we have about you. Ask us how to
do this.
We will provide a copy or a summary of your health information,
usually within 30 days of your request. We may charge a reasonable,
cost-based fee.
Ask us to correct your medical record
You can ask us to correct health information about you that you think
is incorrect or incomplete. Ask us how to do this.
We may say “no” to your request, but we’ll tell you why in writing
within 60 days.
Request confidential communications
You can ask us to contact you in a specific way (for example, home or
office phone) or to send mail to a different address.
We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
You can ask us not to use or share certain health information for
treatment, payment, or our operations. We are not required to agree to
your request, and we may say “no” if it would affect your care. If you
pay for a service or health care item out-of-pocket in full, you can ask us
not to share that information for the purpose of payment or our
operations with your health insurer. We will say “yes” unless a law
requires us to share that information.
Get a list of those with whom we’ve shared information
You can ask for a list (accounting) of the times we’ve shared your health
information for six years prior to the date you ask, who we shared it
with, and why.
We will include all the disclosures except for those about treatment,
payment, and health care operations, and certain other disclosures
(such as any you asked us to make). We’ll provide one accounting a
year for free but will charge a reasonable, cost-based fee if you ask for
another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have
agreed to receive the notice electronically. We will provide you with a
paper copy promptly.
Choose someone to act for you
If you have given someone medical power of attorney or if someone is
your legal guardian, that person can exercise your rights and make
choices about your health information.
We will make sure the person has this authority and can act for you
before we take any action.
File a
complaint if you feel your rights are violated
You c
an complain if you feel we have violated your rights by contacting
us Compliance@kaizo-health.com
You can file a complaint with the U.S. Department of Health and Human
Services
Office for Civil Rights by sending a letter to 200 Independence
Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or
visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
We w
ill not retaliate against you for filing a complaint.
Your Choices
For certa
in health information, you can tell us your choices about what we share. If you have a clear
preference for how we share your information in the situations described below, talk to us. Tell us what
you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to: Share information with your family,
close friends, or others involved in your care; Share information in a disaster relief situation; Include your
information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and
share your information if we believe it is in your best interest. We may also share your information when
needed to lessen a serious and imminent threat to health or safety.
In these cas
es we never share your information unless you give us written permission: Marketing
purposes; Sale of your information; Most sharing of psychotherapy notes
In the case of fundraising - We may contact you for fundraising efforts, but you can tell us not to contact
you again.
Our Uses and Disclosures
We typi
cally use or share your health information in the following ways.
Treat y
ou - We can use your health information and share it with other professionals who are treating
you. Example: A doctor treating you for an injury asks another doctor about your overall health
condition.
Run our or
ganization - We can use and share your health information to run our practice, improve your
care, and contact you when necessary. Example: We use health information about you to manage your
treatment and services.
Bill fo
r your services - We can use and share your health information to bill and get payment from health
plans or other entities. Example: We give information about you to your health insurance plan so it will
pay for your services.
We are allowed or required to share your information in other ways – usually in ways that contribute
to the public good, such as public health and research. We have to meet many conditions in the law before
we can share your information for these purposes. For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help wit
h public health and safety issues - We can share health information about you for certain
situations such as: Preventing disease; Helping with product recalls; Reporting adverse reactions to
medication; Reporting suspected abuse, neglect, or domestic violence; and Preventing or reducing a
serious threat to anyone’s health or safety
Do researc
h - We can use or share your information for health research.
Comply wi
th the law - We will share information about you if state or federal laws require it, including
with the Department of Health and Human Services if it wants to see that we’re complying with federal
privacy law.
Respond to
organ and tissue donation requests - We can share health information about you with
organ procurement organizations.
Work with a medical examiner or funeral director - We can share health information with a coroner,
medical examiner, or funeral director when an individual dies.
Address
workers’ compensation, law enforcement, and other government requests - We can use or
share health information about you: For workers’ compensation claims; For law enforcement purposes or
with a law enforcement official; With health oversight agencies for activities authorized by law; For
special government functions such as military, national security, and presidential protective services
Respond t
o lawsuits and legal actions - We can share health information about you in response to a court
or administrative order, or in response to a subpoena.
Our Responsibilities
• We are r
equired by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time.
Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html
View online at www.kaizo-health.com
Effective 9/23/2013
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this
information. Please review it carefully
.
PATIENT RIGHTS AND RESPONSIBLITIES
You the patient have the right to:
Be treated with dignity and respect
Confidentiality
Participate in the assessment and care planning process
Be provided service in a timely manner
Be notified in advance of types of treatment and frequency of treatment being provided
Be notified of any changes in your plan of care and treatment
Receive an explanation of the billing process and an explanation of charges
Express grievance without fear of reprisal or discrimination
Refuse or discontinue
You the patient are responsible for:
Providing information when services are rendered
Following the treatment plan as outlined by the doctor and scheduling for treatment at least 4
weeks in advance
Notifying practice when you will not be available for treatment or will be late for treatment
Rescheduling any missed treatment in order to keep on schedule as outlined in your treatment
plan
Performing all the rehab exercises including the prescribed home care program as outlined by
the doctor
Notifying the practice of any change in your condition, physician orders, attending physician, or
attorney
Notifying the practice of any incident involving the staff or equipment
Payment of all co-payment or deductible applicable per the insurance plan of your choice
PATIENT EMPOWERMENT CHECKLIST
1. COMMUNICATION - If your condition worsens, please contact your Kaizo Health doctor
immediately. KH doctors are required to give you their cell phone number, their email or both.
2. FOLLOW UP - Follow up with all of your doctor’s self-care advice, such as:
Performing all of your home exercise instructions. If you have any problems
doing your home exercises, inform your Kaizo Health doctor immediately.
Follow up with your icing instructions.
Watch your ergonomics. Take time to evaluate your work station and how you
perform your home related activities and ensure you are always in the “good
posture position.”
3. UNDERSTANDING - Ensure you understand all of your available treatment options, both
inside and outside of Kaizo Health, which your KH doctor has discussed with you.
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Patient Information Marital Status: Single Married Divorced Widowed

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Completed 20 April 2022

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