Ability Health Services & Rehabilitation, LP Patient History Form

Revised: 01.01.17

Patient Name: ________________________________________________________ D.O.B.: _______________________ SSN#:_____________________________________________ E-mail Address: ___________________________ Cell/Phone # ____________________________________________________ Age: ________ Sex: Male Female Marital Status (please circle): Single Married Divorced Religion: ____________________________ Emergency Contact Name: _____________________________________________________Phone #:________________________________Relation:_____________________ Race: Asian/Pacific Islander______ Hispanic______ Black______ Caucasian_______ Eskimo/American Indian________ Other________ Ethnicity: Hispanic or Latino______________ Not Hispanic or Latino_____________ Primary Language ______________________ Insurance are we billing for services rendered? Commercial_____Workers Comp______ Motor Vehicle______ Medicare______ Other____________ Current Problem: _____________________Date of Injury: ___Date of Surgery: Pain level (0-10) Current: ________ Best: ________ Worst: ________ Height: _______________ Weight:_________________ MEDICAL HISTORY (Do you have/had any of the following medical conditions?)_____________________________________________ YES NO YES NO HEART PROBLEMS? ____ ____ PACEMAKER? ____ ____ HIGH BLOOD PRESSURE? ____ ____ DIABETES? ____ ____ TB/HIV/HEPATITIS? ____ ____ CANCER? ____ ____ SEIZURES? ____ ____ PREGNANT? ____ ____ URINARY LEAKAGE? ____ ____ OSTEOPOROSIS? ____ ____ SMOKER? ____ ____ ALCOHOL? ____ ____ If smoker, how often:_________________________________________ If you drink alcohol, how often:_______________________________________ List any ALLERGIES: _________________________________________________________________________________________________________________________________________ List all surgeries, injuries, medical problems, or previous therapy that you have had in the past 5 years? _________________________________________________________________________________________________________________________________________________________________ List any medical conditions that may affect your therapy: _______________________________________________________________________________________________ Has your current situation caused any significant difficulty within your family/social life? YES_____ NO_____ If yes, describe: _______________________________________________________________________________________________________________________________________________ Describe the limitations you have: ________________________________ Your goals for therapy: __________ Employment/Work: Full-time_____ Part-time_____ Homemaker_____ Student_____ Retired_____ Unemployed_____ Occupation: _________________________________Employer: ________________________________Employer Phone: ______________________________________________ Briefly describe your occupation: __________________________________________________________________________________________________________________________ Do you currently use an Assistive Device? YES_____ NO______ If yes: Cane_____ Walker_____ Rolling Walker_____ Motorized Wheelchair_____ Other: _____________________________________________ With whom do you live? Alone_____ Spouse/significant other_____ Child/children_____ relative(s)_____ Group Setting_____ Personal care attendant_____ Other (describe):___________________________________________________________________________________________________________ Do you have a Power of Attorney? YES_____ NO_____ Representative: ____________________________________Phone # _____________________________ (Patient Signature): _ Date:

Ability Health Services & Rehabilitation, LP.

MEDICATION LIST

Patient Name: _____________________________________ DOB: ___________ Date: _________________

Prescription

Medication

Reason for Med Dose Frequency/Mode Prescribed by/Phone #:

Over the Counter

Medication

Reason for Med Dose Frequency/Mode Prescribed by/Phone #:

Patient Signature: ______________________________ Date:_______________________________

Revised: 01.01.17

ABILITY HEALTH SERVICES & REHABILITATION, LP

PATIENT GUIDELINES AND CANCELLATION POLICY

1. Please get to your appointments on time in order to allow adequate time for their therapy. Patients

arriving late for a scheduled appointment may not get full hour of treatment.

2. Please come appropriately dressed in attire that will allow you comfortable movement of the area to be

treated so you are able to perform physical activity such as gym shoes, shorts and t-shirts/tank tops.

3. All patients are required to sign in upon arrival.

4. Food, gum, and drinks other than water are not permitted in the patient treatment areas.

5. Cell phones should be turned off or be on vibrate to avoid disturbing other patients or interrupt

treatment.

6. Patients are required to wait in the waiting room areas until they are called in by a clinician.

7. Only the patient is permitted to go in the treatment area. Other adults or children are not permitted in

the treatment area unless prior arrangements have been made. Children are never permitted to use any

clinical equipment unless they are being treated.

8. A release for treatment must be filled out by any parent that must leave their children under the age of

18 during their therapy session. Children must be picked up promptly following therapy.

9. If you or your child are unable to keep your appointment due to illness or any other reason, please call at

least 24 hours in advance to reschedule your appointment. A cancellation/ no-show fee of $30.00 may

be charged.

10. Attending your scheduled therapy sessions is one aspect of your treatment that you can control. In the

event of cancellation of less than 24 hours, or you miss your appointment the following policies will

apply:

- First offense- we will verbally request to follow our cancellation policy.

- Second offense- your physician, case manager, and/or insurance company will be notified if you miss

your appointment without reasonable cause.

- Third offense- inability to schedule with written notification of non-compliance to physician, case

manager, and/or insurance company.

Your signature certifies that you have read the Cancellation Policy and accept its terms

_________________________________________________________________________ _______________________

PATIENT/GUARDIAN DATE

_________________________________________________________________________ _______________________ RELATIONSHIP TO PATIENT DATE

ABILITY HEALTH SERVICES & REHABILITATION, LP

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

Ability Health Services, Inc My “protected health information” means health information, including my demographic

information, collected from me and created or received by my physician, rehab facility, another

health care provider, a health plan, and my employer or a health care clearinghouse. This

protected health information relates to my past, present, and/or future physical or mental health or

condition and identifies me, or there is a reasonable basis to believe the information may identify

me. I understand I have the right to request a restriction as to how my protected health

information is used or disclosed to carry out treatment, payment, or healthcare operations of the

practice. Ability Health Services is not required to agree to the restrictions that I may request;

however, if Ability Health Services agrees to a restriction that I request then the restriction is

binding. I have the right to revoke this consent, in writing, at any time, except to the extent that

Ability Health Services has taken action in reliance on this consent.

I understand I have the right to review Ability Health Services Notice of Privacy Practices, which

has been made available to me, prior to signing this document. The Notice of Privacy Practices

describes the types of uses and disclosures of my protected health information that will occur in

my treatment, payment of my bills, and in the performance of health care operations of the

Ability Health Services. The Notice of Privacy Practices for Ability Health Services is also

posted at each office location and on the Ability Health Services website at

www.abilityrehabilitation.com This Notice of Privacy Practices also describes my rights and

Ability Health Services duties with respect to my protected health information. Ability Health

Services reserves the right to change the privacy practices that are described in the Notice of

Privacy Practices. I may obtain a revised notice of privacy practices by accessing the Ability

Health Services website, calling the office and requesting a revised copy be sent in the mail, or

asking for one at the time of my next appointment.

_________________________________ _______________________________ Date

Signature of Patient or Personal Representative

____________________________________ _______________________________ Personal Representative’s Authority

Print Name of Patient

I hereby authorize the release of my Protected Health Information to the following individuals

(Please Print NAME AND RELATIONSHIP):

______________________________________________________________________________

________________________________________________________________________

______________________________________________________________________________

OFFICE USE ONLY

I attempted to obtain the patients signature in acknowledgement on this Notice of Privacy

Practices Acknowledgement, but was unable to do so as documented below:

Date:

Initials: Reason:

REVISED 01.01.17

Women’s Pelvic Floor Intake Form

Name: ___________________________ Please fill out the following questions to the best of your ability. These will be reviewed with your therapist.

History Number of pregnancies: ________ Complications: ____________________________________________

Number of vaginal deliveries: ______ Number of C-sections: _______ Number of episiotomies:

______

Do you have a history of infections, Vaginal, UTI or other? ____ Y ____N If yes, please list diagnosis and treatment: _____________________________________________ Test Results (please circle) Urodynamic test: Y N Results: _________________________________________ Cystoscopy Y N Results: _________________________________________ Colonoscopy Y N Results: _________________________________________ MRI/X-ray/Ultrasound Y N Results: _________________________________________ Other tests: Y N Results: _________________________________________ Pain Do you have pain with any of the following (please circle)?

Pelvic exam Y N at low abdomen Y N Tampon use Y N at groin/hips/low back Y N Sexual intercourse Y N Other: ___________________________________________

Bladder Do you lose urine? Y N How often? ________ times/day When? Please circle all that apply: Coughing/laughing On the way to the bathroom Exercising Sneezing When you experience strong urge Running/Jumping Hear running water Getting in/out of chair or bed Lifting

Do you wear any garments due to leaking? _____Pullup briefs _____ Pads _____ toilet paper How many garments used per day? _____ How often do you urinate? Every: ____ Less than 1 hour ____1 hour____ 2 hours____ 3 hours____ 4 hours____ 5 hours or more During the night: ____1 ____2 ____3 ____4 or more Do you have pain with full bladder? Y N Need to strain to empty? Y N Difficulties emptying bladder? Y N Heavy pressure with voiding? Y N Bowel How often do you have a bowel movement: _______ per day or _____ per week? Most common stool consistency? ____Liquid ____ Soft ____ Firm/Formed ____ Hard/pebbles Do you often feel constipated? Y N Do you need to strain? Y N Require laxatives? Y N If yes, what/how often: _____________________ Do you have diarrhea often? Y N Experience strong urge? Y N Leak gas/feces? Y N If yes, how often? ___________________________ Do you wear garments due to leaking stool? Y N Patient Signature: ____________________________________ Date: ___________________________

Rev 4/28/2018

Men’s Pelvic Floor Intake Form

Name: ___________________________ Please fill out the following questions to the best of your ability. These will be reviewed with your therapist.

History Prostatitis Y N Treatment: _____________________________________________ Prostate cancer Y N Surgery date/type: _____________________________________ History of infections? Y N If yes, please list diagnosis and treatment: ______________________________________________________________________________________________ Test Results (please circle) Urodynamic test: Y N Results: _________________________________________ Cystoscopy Y N Results: _________________________________________ Colonoscopy Y N Results: _________________________________________ Anorectal Manometry Y N Results: _________________________________________ MRI/X-ray/Ultrasound Y N Results: _________________________________________ Other tests: Y N Results: _________________________________________ Pain Do you have pain with any of the following (please circle)?

Below waist pubic or bladder area Y N Testicles Y N Between rectum and testicles Y N Tip of penis Y N During or after ejaculation Y N Other: ________________________________________________________________________________

Bladder Do you lose urine? Y N How often? ________ times/day When? Please circle all that apply: Coughing/laughing On the way to the bathroom Exercising Sneezing When you experience strong urge Running/Jumping Hear running water Getting in/out of chair or bed Lifting Do you wear any garments due to leaking? _____Pullup briefs _____ Pads _____ toilet paper How many garments used per day? _____ How often do you urinate? Every: ____ < 1 hour ____1 hour ____2 hours____ 3 hours – 4 hours During the night: ____1 ____2 ____3 ____4 or more Do you have pain with full bladder? Y N Need to strain to empty? Y N Difficulties emptying bladder? Y N Heavy pressure with voiding? Y N Difficulties starting stream? Y N Weak stream? Y N Post void dribble? Y N Bowel How often do you have a bowel movement: _______ per day or _____ per week? Most common stool consistency? ____Liquid ____ Soft ____ Firm/Formed ____ Hard/pebbles Do you often feel constipated? Y N Do you need to strain? Y N Require laxatives? Y N If yes, what/how often: ______________ Do you have diarrhea often? Y N Experience strong urge? Y N Leak gas/feces? Y N If yes, how often? ____________________ Do you wear garments due to leaking stool? Y N Patient Signature: ____________________________________ Date: ___________________________

Rev 4/28/2018