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2. medicine
3. surgery

Print Forms
Patient Intake Form
2000 W Wickenburg Way #200, Wickenburg AZ
Phone: 928-668-0108; Fax 928-668-0110
First Name: ____________________________
Middle Init: _______ Last Name: _____________________________
Preferred Name (if different): __________________________ Social Security No.: _____________________________
Birthdate: ________________________
Gender: ⃝ M ⃝ F
Marital Status: ⃝ Single ⃝ Married ⃝ Widowed
If Patient is a Minor, Parent(s) or Guardian’s name: ________________________________________________________
Email (used for appointment reminders): ________________________________________________________________
Primary Phone No.: ______________________________________________ Type: ⃝ Cell ⃝ Home ⃝ Work
Secondary Phone No.: ____________________________________________ Type: ⃝ Cell ⃝ Home ⃝ Work
Mailing Address: ___________________________________________________________________________________
Physical Address, if different: _________________________________________________________________________
How did you hear about us? __________________________________________________________________________
Employment Status: ⃝ Full-time ⃝ Part-time ⃝ Retired ⃝ Student
Occupation/Job Title: ________________________________________________________________________________
Employer: _________________________________________________
Employer Phone No.: ____________________
Referring Physician
Physician Name: ___________________________________________
Phone No.: ____________________________
Emergency Contact Information
Name of Emergency Contact: _________________________________________________________________________
Relationship to Patient: ______________________________________
Phone No.: ____________________________
Insurance Information (Please give your insurance cards and photo id to the receptionist.)
Is your treatment today regarding either a work-related accident or an auto-accident injury? ⃝ Yes ⃝ No
Primary Insurance _______________________________________________ Group No.: ________________________
Subscriber’s Name, if other than patient: _____________________________ Policy No.: ________________________
Patient’s Relationship to Subscriber: ⃝ Self ⃝ Spouse ⃝ Child ⃝ _______ Subscriber’s Birthdate: ______________
Secondary Insurance _____________________________________________ Group No.: ________________________
Subscriber’s Name, if other than patient: _____________________________ Policy No.: ________________________
Patient’s Relationship to Subscriber: ⃝ Self ⃝ Spouse ⃝ Child ⃝ _______ Subscriber’s Birthdate: ______________
I hereby certify the above information is true and correct to the best of my knowledge. I understand that while Champion Physical Therapy contracts with many
insurance companies, it is my responsibility to verify with my plan that Champion Physical Therapy is a participating provider. It is also my responsibility to find out
what my coverage options are with my insurance plan. I further understand that Champion Physical Therapy will assist me in obtaining authorization from my primary
care physician or insurance company if necessary. If however, authorization is not obtained, I may be financially responsible for services rendered. I hereby authorize
Champion Physical Therapy to submit insurance claim forms along with medical records necessary to obtain payment from my insurance company. I understand that
I am responsible for all charges regardless of insurance coverage. I acknowledge that photo IDs taken are used to assist in patient recognition per HIPAA guidelines.
Signature: ______________________________________________________
Date: ___________________________
Patient Medical History
Patient Name: ___________________________________________________ Date: ___________________________
Mark the column labeled “YES” for those conditions you are CURRENTLY experiencing:
YES
YES Osteoporosis
⃝ Asthma, Bronchitis, or Emphysema
⃝ Sleeping Difficulties
⃝ Shortness of Breath / Chest Pain
⃝ Bowel or Bladder Problems
⃝ High Blood Pressure
⃝ Weight Loss / Gain
⃝ Epilepsy / Seizures
⃝ Any Pins or Metal Implants
⃝ Anemia
⃝ Emotional / Psychological
⃝ Diabetes / Type _________
⃝ Pregnant
⃝ Arthritis / Where? _______________
⃝ Smoking
⃝
None of the Above
Mark the column labeled “YES” for those conditions you have EVER had:
YES
Date
YES
⃝ Coronary Heart Disease or Angina
⃝ Hernia
⃝ Pacemaker / Defibrillator
____________
⃝ Joint Replacement Surgery
⃝ Heart Attack / Heart Surgery
____________
⃝ Ankle / Foot Injury / Surgery
⃝ Stroke / TIA
____________
⃝ Neck Injury / Surgery
⃝ Blood Clot / Emboli
____________
⃝ Back Injury / Surgery
⃝ Infectious Disease
____________
⃝ Shoulder Injury / Surgery
⃝ Cancer / Type ________________ ____________
⃝ Knee Injury / Surgery
⃝ Gout
⃝ Elbow / Hand Injury / Surgery
⃝ Vision or Hearing Difficulties
⃝ Other____________________
⃝
Date
____________
____________
____________
____________
____________
____________
____________
None of the Above
Medications
Please list any medications you are taking (or provide us with a photocopy), with the dose and frequency.
Medication Name
Dose (i.e. 10 mg)
Frequency (i.e. one a day)
Please list Vitamins, Supplements, and Over-the-Counter Medicines
Patient/Parent/Guardian Signature: ____________________________________________________________________
Injury Assessment Form
1. Patient Name: _______________________________________ Injury: ____________________________________
2. Date of Injury/Onset of Episode?_________________________ Have you had surgery for this injury? ⃝ Yes ⃝ No
3. Type of Surgery: _________________________________
Number of Surgeries: ____ Date of Surgery: __________
4. Have you received any of the following medical or rehabilitative services to treat this injury or episode?
Services
Physical Therapy
Chiropractic
Podiatric
Neurologic
Orthopedic
Home Health
Not
No Helpful Helpful
Yes
Service
Injections
Narcotic
MRI
X-Ray
CT Scan
EMG/NCV
Yes
Not
No Helpful Helpful
5. How often does the pain occur? ⃝ Constant ⃝ Several Times a Day ⃝ Several Times a Week
6. Please mark the area on the picture where you feel pain or other symptoms.
Right
Side
L
7. Rate Your Pain Below:
R
R
L
Left
Side
0 = No Pain
10 = Take Me to E.R.
At its WORST in the past three days:
0
1
2
3
4
5
6
7
8
9
10
Right Now:
0
1
2
3
4
5
6
7
8
9
10
At its BEST in the past three days
0
1
2
3
4
5
6
7
8
9
10
8. How do you describe the pain? ______________________________________________________________________
9. What aggravates your pain? ________________________________________________________________________
10. What relieves your pain? __________________________________________________________________________
11. Do you have numbness, weakness, or tingling? ⃝ No ⃝ Yes, where: _____________________________________
12. Do you experience dizziness or fainting? ⃝ No ⃝ Yes, when: __________________________________________
13. What are your goals/expectations from physical therapy?________________________________________________
Print Forms
Consent Form
Patient Name: ___________________________________________________ Date: ___________________________
______Consent for Evaluation and Treatment
I hereby agree and give consent for myself, or as parent/guardian for my minor child, for Champion Physical
Therapy to furnish medical care and treatment considered necessary and proper in diagnosing and treating my
physical condition.
______Consent to Release Medical Information
I authorize Champion Physical Therapy to release any information, verbal and written, acquired in connection
with my therapy services including, but not limited to, diagnosis, medical records, and other related information,
to myself, my insurance company, case manager, attorney, related healthcare provider, assignees and/or
beneficiaries as it relates to my treatment or payment for services provided.
______Consent to Obtain Medical Information
I authorize Champion Physical Therapy to obtain medical records and/or professional information from my
physician or other medical professional as it relates to my treatment.
______Acceptance of Cancellation Policy
I agree to notify Champion Physical Therapy 24 hours prior to my appointment should I need to cancel or
reschedule. I also understand if my therapy is covered by a worker’s compensation carrier, Champion Physical
Therapy is required to notify my case manager if I cancel an appointment and do not reschedule, or if I fail to
keep a scheduled appointment.
______Assignment of Insurance Benefits
I authorize and assign direct payment to Champion Physical Therapy of any sum now or hereafter owed. I give
assignment and lien against any claims against a third party whose negligence may have caused me injury, up to
the amount of the bill for treatment.
______Guarantee of Payment
I understand that I am 100% responsible for all fees incurred here at Champion Physical Therapy that are not
covered by my insurance plan. I agree to pay any unpaid balances for services rendered. I understand and
agree that if I fail to make any of the payments for which I am responsible in a timely manner, my account will
be referred to a collection agency or attorney, and I will be responsible for all costs of collecting monies owed,
including court costs, collection fees and attorney fees.
______Acknowledge Receipt of Privacy Practices
I acknowledge I have reviewed the Privacy Practices for Champion Physical Therapy. A copy of this notice is
available upon my request.
Agreement to Disclose Protected Health Information to Named Persons
I hereby agree, Champion Physical Therapy may disclose any and all of my protected health information to the
following individuals, all of whom are involved in my care for any purpose related to my treatment or the
payment of my care.
Name: ___________________________________________________ Relationship: _____________________
Name: ___________________________________________________ Relationship: _____________________
Patient/Parent/Guardian Signature: ____________________________________________________________________