Health History & Consent

Please complete this form so that your physical therapist can conduct a thorough examination and create the optimal treatment plan for you. Physical therapists need to know your full medical history.

Demographic Information

Patient's Name(Required)

First Middle Last

Patient's Email Address(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Marital status(Required)

Gender at Birth(Required)

Female

Male

Do You Identify as your Birth Gender?(Required)

Yes

Emergency Contact Name(Required)

Relationship to Patient(Required)

Emergency Contact Phone(Required)

Are You Currently Employed?(Required)

Yes

Occupation(Required)

If not employed, please enter homemaker / retired / student / unemployed or other descriptor.

Employer(Required)

Work Phone(Required)

Describe the positions, movements and activities you do for work:(Required)

Examples: sitting, standing, walking, lifting, computer use, etc..

Who Do You Live With?(Required)

Select all that apply.

Alone

Spouse / Partner / Significant Other

Child(ren)

Parents

Caregiver

Roommate(s)

Other

Do you use any assistive devices for mobility or safety?(Required)

Yes

Occasionally

Have you fallen in the past 12 months?(Required)

Yes

How many falls?(Required)

Please rate your present health(Required)

Excellent

Good

Fair

Poor

Are You Pregnant?(Required)

Yes

Not Applicable

Estimated Due Date:(Required)

Do you use tobacco products?(Required)

Yes

Not currently, but I have in the past

How many cigarettes/cigars/chews per day?(Required)

When did you quit?(Required)

Do you drink alcoholic beverages?(Required)

Yes

How many drinks per week?(Required)

How many hours of sleep do you typically get each night?(Required)

Do you feel well rested when you wake up?(Required)

Yes

Other

How would you rate your sleep quality?(Required)

Do you exercise beyond daily activities and chores?(Required)

Yes

How many days per week do you exercise?(Required)

In which ways do you normally exercise? Include activities in all four seasons:(Required)

Please list any life changes and/or stressors this past year:(Required)

Condition to be Treated

How did the condition that we are treating you for start?(Required)

Select all that apply

Injury

Gradual onset

Surgery

Accident

Unsure

Date of surgery:(Required)

Type of surgery:(Required)

List any other treatments or consultations you've had for this condition:(Required)

Examples: other PT, chiropractic, massage, MDs, specialists, etc. Write "none" if this is your first time addressing this condition.

List any tests you've had for this condition:(Required)

Examples: imaging, blood work, other diagnostic tests. Write "none" if no tests have been done.

How are your symptoms / condition changing?(Required)

Improving

Getting worse

Not changing

Other

Medication List

List all prescribed medications(Required)

Enter "none" if you don't take prescription drugs

List all over-the-counter medications and/or supplements that you take:(Required)

Enter "none" if you don't take over-the-counter medications or supplements

Past Medical & Surgical History

Enter all previous injuries, conditions, degenerative changes or surgeries related to the musculoskeletal system (joints, bones, spine, tendons, muscles, ligaments and fascia)(Required)

Enter "none" if you have no prior history related to the musculoskeletal system

Female medical history(Required)

Select all that apply

Male medical history(Required)

Select all that apply

Prostate cancer

Prostate surgery

Testicular cancer

Vasectomy

Other

None

Other option selected- please list:(Required)

Do you have osteoporosis or osteopenia?(Required)

Yes

Haven't been tested

Do you have epilepsy or seizures?(Required)

Yes

Are you diabetic?(Required)

Yes

Type of diabetes(Required)

Non-insulin dependent - lifestyle controlled

Non-insulin dependent - medication controlled

Insulin dependent

Have you had problems with your heart, lungs, blood vessels or abnormal blood work?(Required)

Yes

Not sure

Check all that apply(Required)

Other option selected- please list:(Required)

Do you have, or have you ever had, a cancer, tumor or malignancy?(Required)

Yes

Not sure

Check all that apply(Required)

If your malignancy isn't listed - please select one of the "other" choices and we will discuss during your appointment

Lung cancer

Colon cancer

Skin cancer

Bone cancer

Leukemia cancer

Lymphoma cancer

Other non-cancerous tumor

Other cancer not listed

Other option selected- please list:(Required)

Have you ever been diagnosed with a neurological problem (brain, spinal cord or nerves)?(Required)

Yes

Not sure

Check all that apply(Required)

Other option selected - please list:(Required)

Have you ever been diagnosed with allergies, an autoimmune or inflammatory problem?(Required)

Yes

Not sure

Check all that apply(Required)

Multiple sclerosis

Rheumatoid arthritis

Celiac disease

Ankylosing spondylitis

Gout

Seasonal allergies

Other allergic, autoimmune or inflammatory problem

Other option selected- please list:(Required)

Have you experienced problems related to your mood, memory, behavior or addiction?(Required)

Yes

Not sure

Check all that apply(Required)

Other option selected- please list:(Required)

Have you had an infection or virus that was treated with antibiotics or anti-viral medication?(Required)

Yes

Check all that apply(Required)

Bronchitis

Pneumonia

Tuberculosis

Urinary Tract (bladder) Infection(s)

COVID-19

Shingles

Bone or joint infection

Kidney infection

Other

Other option selected- please list:(Required)

Have you had conditions or surgeries related to your internal organs (stomach, bowel, colon, liver, gall bladder, spleen, kidneys)?(Required)

Yes

Check all that apply(Required)

Other option selected- please list:(Required)

Consent For Treatment

Consent for Treatment & Financial Policy(Required)

I authorize the staff at Physical Therapy at Thrive, LLC to undertake such treatment and procedures as deemed appropriate to improve my condition. It is recognized that the practice of medicine is not an exact science and, as such, no guarantees are made by the staff of Physical Therapy at Thrive, LLC as to the results of treatment or interventions performed. I am advised that I have the full right to an explanation of treatments or procedures utilized including their benefits and risks as well as reasonable alternatives to the proposed therapy. I understand I have the right to refuse treatment; but, in doing so, I also understand that the desired outcome of my treatment program may be affected. Persistent refusal to participate or cooperate in the recommended treatment program may result in my discharge from the therapy program. I agree that as a patient of Physical Therapy at Thrive, LLC, I authorize the physical therapists to evaluate and treat within the scope of physical therapy practice.

PERSONAL PROPERTY
It is understood that Physical Therapy at Thrive, LLC shall not be liable for loss or damage to any personal items brought to Physical Therapy at Thrive, LLC during my course of treatment.

RELEASE OF INFORMATION
I hereby authorize Physical Therapy at Thrive, LLC to furnish medical records, via fax or mail, to my referring physician, insurance carrier and to any physician to whom I am referred concerning my evaluation and treatment.

WORKERS COMPENSATION PATIENTS RELEASE OF INFORMATION
I authorize Physical Therapy at Thrive, LLC to discuss/forward any relevant vocational information, as related to my rehabilitation, with my worker's compensation/group insurance carrier/external case manager.

ASSIGNMENT OF BENEFITS
I hereby assign all of my right, title, and interest to Physical Therapy at Thrive, LLC of insurance/health and welfare benefits otherwise payable to me, not to exceed the balance due of Physical Therapy at Thrive, LLC customary charges for the services provided.

FINANCIAL CONSENT
I agree to be responsible for payment of all outpatient physical therapy charges which are not covered by insurance. Deductibles, co-pays or co-insurance that is owed will be paid at the time of service unless other arrangements have been made with Physical Therapy at Thrive, LLC. I understand Physical Therapy at Thrive, LLC will bill me, my family, and/or other responsible parties for services provided that are not covered by insurance. Full and earnest attempts to collect all allowed amounts is required for all patients; however, if the patient fails to make some effort to clear or contribute to the reduction of his/her balance within 90 days, Physical Therapy at Thrive , LLC will send the balance to Bonneville Collections. This agency (Bonneville Collections) will conduct collection activities in compliance with The Fair Debt Collection Practices Act and other Federal, State and local laws.

MAINTAINING CREDIT CARD ON FILE
I authorize Physical Therapy at Thrive, LLC to keep my credit card on file without obtaining additional signatures. Upon completion of treatment, any remaining balance will be charged in accordance with my insurance provider's Explanation of Benefits.

I have read, understand and agree to the Consent for Treatment and Financial Policy.

Who is signing this form?(Required)

Reason patient is unable to sign:(Required)

Patient is a minor

Patient is legally blind

Patient has cognitive barriers

Patient has physical barriers

Patient requests assistance

Other

Date(Required)

Phone

This field is for validation purposes and should be left unchanged.

Monday	8:15am - 6:15pm
Tuesday	8:15am - 6:15pm
Wednesday	8:15am - 6:15pm
Thursday	8:15am - 6:15pm
Friday	8:15am - 4:00pm