This individualized plan is created with input from you, your therapist, and your doctor to help the patient achieve their goals as quickly as possible.
Moving forward in filling the form may take 15-20 minutes.
You may choose more than one by using CTRL button and selecting more than one.
Patient Information
Now we will begin asking Patient Personal Information. This is just the patient name, age, and additional details
Now We Are Going To ask Some Questions For Emergency Contact
In case of Emergency whom we should contact
I authorize the release of any necessary information to process my claims and secure benefits.
Now We Are Going To ask Some Questions For Your Physical Therapy Evaluation
To help us assess the cause of your problem, we ask you to complete this form before being seen by a physical therapist. Please answer as completely as possible.
What happened to cause the fall, what hurts because of it and is this the result of something else?
Any type of activities and or sports you do on a regular basis
Now We Are Going To ask Some Questions about complaints and pains
To help us assess the cause of your problem, we ask you to complete this form before being seen by a physical therapist. Please answer as completely as possible.
Please list anything you can think of that causes the pain to be worse
Please list anything that helps lessen the pain from positions to ice, to stretches.
Now We Are Going To ask Some Questions about The History Of your injury
To help us assess the cause of your problem, Please fill out as much information as you can about what, how, why this started and the medical history to make sure we understand.
This could be what you were doing, what happened as a result or anything that might give us an idea of what caused this.
Please give us as much information as possible and close dates of when you have had surgery and what it was for.
In the past year have you had a MRI or Xray
You Can Choose more than one.
Now We Are Going To ask Some Questions about Medication History
Due to insurance regulations, we must keep a record of any medications you are taking. Please take the time to all out your medications, dosages and the reason for taking medications.
Notice of Patient Information Practices
This notice describes how medical information about you may be used or disclosed and how you can get access to information. Please review carefully.
I hereby consent to using and disclosing my personal health information for purposes as noted in the Atala Physical Therapy’s Notice of Information Practices. I understand that I retain the right to revoke this consent by notifying the practice at any time.
I hereby consent to using and disclosing my personal health information for purposes as noted in the Atala Physical Therapy’s Notice of Information Practices. I understand that I retain the right to revoke this consent by notifying the practice at any time.
**Our official corporate name is Atala Physical Therapy, Inc.
Thus, this official name may appear on your billing/credit card statement.**
As a new patient of Atala Physical Therapy, I hereby acknowledge and understand the following.
Physical therapy means the art and science of physical or corrective rehabilitation or physical or corrective treatment of any bodily or mental condition of any person by the use of the physical, chemical, and other properties of heat, light, water, electricity, sound, massage, and active, passive, and resistive exercise, and shall include physical therapy evaluation, treatment planning, instruction and consultative services (collectively “Therapy”).
The practice of physical therapy includes the promotion and maintenance of physical fitness to enhance the bodily movement related to the health and wellness of individuals through the use of physical therapy interventions. Physical therapists are not authorized in California to diagnose disease(s).
Atala Physical Therapy does not discriminate, and therapy being provided by Atala Physical Therapy is provided without regard to the patient’s race, religion, gender, color, national origin, ancestry, physical handicap, medical condition, marital status, age, or sex. Response to therapy treatment varies by individual. Therefore, it cannot and Atala Physical Therapy has not, predicted my response to therapy.
While the goal is for improvement of the condition in which I am seeking therapy, I understand that there is a possibility that my condition may worsen and therapy may cause pain, injury and even death. I also understand and acknowledge that I may develop new or different injuries as a result of my participation in a physical therapy program and in receiving therapy.
With full knowledge of the above, I hereby knowingly and voluntarily assume any risks associated with the therapy that I receive, and I, along with my heirs and assigns, fully and forever release Atala Physical Therapy, its owners, partners and providers of therapy services from any and all injury which may naturally occur and which are inherent in receiving therapy.
