Pelvic Floor Intake Form

Patient Information:

YOU WILL RECEIVE THE CHOSEN REMINDER ONE DAY BEFORE YOUR APPOINTMENT (OR ON FRIDAYS FOR MONDAY APPTS.) HOWEVER, PLEASE NOTE THAT THE APPOINTMENT YOU MAKE IS YOUR RESPONSIBILITY TO KEEP, REGARDLESS IF YOU RECEIVE YOUR REMINDER OR NOT. This is a courtesy service that usually works, under some circumstances reminders have not been delivered (ie. blocks on cellular services, same phone number for family members).

Patient Responsibility and Authorization:

Notice of Privacy Practices

Please check below to acknowledge that you have access or can obtain a copy of our Notice of Privacy Practices from the front desk at any time. It addresses how your health information may be used, disclosed and accessed. HIPAA

Cancellation policy

We have reserved your appointment time just for you. You are responsible to show up for your appointment or cancel at least 24 hours in advance. If you do not, we charge a $45.00 no show/cancellation fee for the 1st and 2nd missed appointment, and $95 for the 3rd and 4th missed appointment. This fee must be paid before another appointment is scheduled. Any additional no-shows and you will be discharged from the clinic..

Please indicate your acknowledgement to the following by initialing each item.

Assignment of Benefits

If my insurance is being billed, I authorize Emergence Physical Therapy to release to my insurance company any information which may be necessary to process my insurance claim. I also assign the benefits which are payable for my services to Emergence Physical Therapy.

Deductible, co-payments and co-insurances

If you have a deductible that has not been met, your insurance will not pay us for your visits until your annual deductible is satisfied. Our policy is to collect an amount to offset your final balance until your deductible is satisfied. The deposit amount for your first visit is dependent on insurance, and for follow ups the amount is $100. After your insurance processes your visit and sends us the explanation of benefit, we will apply the amount you have paid and bill you for the balance. There will be another bill due. If there is a credit on your account after the insurance processes those visits, there will be a refund issued.

You may have a co-payment or coinsurance amount that you are responsible for each visit that we collect at the time of treatment. A final bill may be sent after we receive the explanation of payment from your insurance.

Since your insurance coverage is a contract between you and the insurance company, it is ultimately your responsibility to understand your benefits. If there is a discrepancy of benefits quoted, the plan terms prevail since Emergence P.T. is only a third party to you and your insurer.

Unless prior arrangements are made, all balances are due within 30 days of being billed. Failure to pay or communicate with the office will result in your account being turned over to collections. In Oregon, the spouse’s credit will be affected, as well as yours, and additional fees may incur.

Annual number of visits

Most insurance policies have an annual limit to the number of physical therapy visits you can have. You are responsible for knowing and tracking the number of visits for physical therapy allowed by your insurance plan. PT visits at other facilities are included in that number and treatment for multiple injuries or surgeries also count. If the annual number is exceeded, you are responsible to pay out of pocket. We will do our best to assist you when asked about the count, but you are ultimately responsible.

Informed Consent

I acknowledge and consent to the performance of physical rehabilitation including various modes of manual therapy from Emergence’s practitioners, which may include spinal manipulation and/or mobilizations if deemed applicable on me. Prior to the treatment, there will be an explanation of how it will benefit and what is to be expected. I understand and am informed that there are some risks to treatments, in which the provider will follow evidence based practice to determine course of the procedure.

Patient Insurance Information:

Primary Insurance Information

(if Workers’ Compensation or MVA, see below)

Patient Questionnaire/History:

Draw a mark or circle your problem on the body chart below.

Pelvic Symptom Questionnaire:

Patient Medical History:

1) Fever/chills
2) Unexplained weight change
3) Dizziness or fainting
4) Change in bowel or bladder functions
5) Malaise (unexplained tiredness)
6) Unexplained muscle weakness
7) Night pain/sweats
8) Numbness/tingling
10) Do the current problems interrupt your sleep?
11) Do your symptoms change with coughing or sneezing?
12) Have you had any recent changes in bowel or bladder function?
13) Do you experience any dizziness or vertigo?
14) Have you had any recent change in your weight or appetite?
15) Do you have any intolerance to hot or cold?
16) Do you have any bruising or bleeding disorders?
17) Have you had any skin changes, such as rashes or discoloration?
18) Have you experienced any changes in your vision, such as blurring, double vision, or descrease in your visual fields?
19) Have you had a recent episode of nausea/vomiting?
20) Are you pregnant?
21) Do you have osteoporosis?
22) Do you have any allergies?
23) Have you noticed any shortness of breath or decrease in exercise tolerance?
24) Do you use any assistive device? (cane/foot orthotics)
25) Do you have high blood pressure?
26) Do you have any cardiac problems?
27) Do you have diabetes?
28) Have you ever had cancer of any sort?
29) Do you have a history of neck or back problems?
30) Do you have any neurological conditions such as: multiple sclerosis, fibromyalgia?
31) Do you have a history of head trauma, headaches, migraines?
32) Do you have acid reflux/belching?
33) Have you been diagnosed with hypothyroidism/hyperthyroidism?
34) Do you have kidney problems?
35) Do you have irritable bowel syndrome?
36) Do you have a past or current history of physical or sexual abuse?
37) Do you have a past or current history of an eating disorder?
38) Do you have a past or current history of substance abuse?
39) Do you have a history of pelvic, sacroiliac or tailbone pain?
40) Do you have a past or current history of depression?
41) Do you have a past or current history of a sexuality transmitted disease/infection?
42) Do you have a history of childhood bowel/bladder issues?

Patient Social History:

Family medical History: