Medical History Form Step 1 of 8 12% Name* First Last Age*Gender*MaleFemaleOccupation*How did you hear of us?*My DoctorYelp!GoogleFacebookInstagramOtherYour Doctors NameSo we can send them a Thank You!OtherPlease be specific so we can send a Thank You!Please provide a brief explanation about why you are seeking physical therapy:*When did it begin?*1-2 Weeks2-3 Weeks3-4 Weeks1-2 Weeks2-3 WeeksMore than 2 monthsMore than 6 monthsMore than 1 yearDescribe your symptoms:Since the original onset of your symptoms, has it:Gotten worseGotten betterNo changePlease select your Therapist:*Dr. Paul Ochoa DPT, OCS, CMPTDr. Andrew Eisen DPT, OCSDr. Monique Dupree PT, DPT Save and Continue Later Pain ScaleWhat is your pain when it is worst?*No painMild painModerate painSevere painWhat is your pain, currently?*No painMild painModerate painSevere painWhat is your pain when it is best?*No painMild painModerate painSevere painWhen are your symptoms worst?*MorningAfternoonEveningAfter excerciseWhen are your symptoms best?*MorningAfternoonEveningAfter excerciseHow do your symptoms affect your sleep?No problemAwakened infrequentlyAwakened frequentlyUnable to sleep without medicationCause of Current Issue:*Chronic symptomsMotor vehicle accidentSports or recreational injuryRepetitive motionTraumaPost surgicalUnknownHave you had previous treatment for this condition?(Physical therapy, chiropractic, surgery, etc)?Have you recently had any tests performed for this condition?(MRI, X-Ray, etc)?What are your goals for physical therapy? Save and Continue Later Medical HistoryLeisure activities, exercise routines, etc:Do you have a pacemaker? (leave blank if 'No')If so, when was it placed?Do you smoke?No1/2 pack daily1/2 - 1 pack dailyMore than 1 pack dailyDo you have any allergies? (leave blank if 'No')If yes, what?WOMEN: Are you currently pregnant? (leave blank if 'No')If so, how far along?Have you recently had any of the following:* Fever Nausea/ Vomiting Sudden weight loss/ gain Heartburn/ indigestion Loss of balance Sudden dizziness/ lightheadedness Changes in bowel/ bladder function Difficulty swallowing Headaches Muscle weakness Numbness/ tingling Diarrhea/ constipation None Other OtherEnter other condition here:Are you CURRENTLY or RECENTLY taking any medications? (leave blank if 'No')If yes, please list all medications.Have you had any prior surgeries? (leave blank if 'No')Are there any other medical/ orthopedic issues you would like us to be aware of? (leave blank if 'No')Do you have an IMMEDIATE FAMILY history of any of the following?* Cancer High blood pressure Diabetes Early onset osteoporosis Heart problems Blood clots None Other OtherEnter other here: Save and Continue Later F2PT Demographics FormAddress* Street Address City State / Province / Region ZIP / Postal Code Email* Phone*Date of Birth* Emergency Contact NameEmergency Contact phone number Save and Continue Later Insurance InformationPrimary Insurance CompanyMember IDSecondary Insurance Company (If Applicable)Member ID Save and Continue Later Patient Responsibilities- I request that payment of benefits be made on my behalf to F Squared Physical Therapy for any services rendered. -I understand and acknowledge that submission of claims is not a guarantee of payment. If for any reason my carrier does not cover and/or all of my physical therapy treatments, I agree that I am responsible for the payment of the entire amount. -I understand that it is my responsibility to obtain a new prescription at the end of the specified time period. If I fail to obtain an updated prescription, I understand that I will be responsible for payment of services not covered by my carrier. -I understand that it is my responsibility to make sure that my bills are paid in a reasonable time (no longer than 1 month from the date of treatment). If for any reason any portion of my bill is not paid, I understand that I am financially responsible for charges for services rendered. -I understand and agree that if my carrier makes any payments directly to me for services rendered, i will remit the same payment to F Squared Physical Therapy. -I understand that it is my responsibility to notify F Squared Physical Therapy of any changes to my insurance carrier or coverage as soon as possible. Any failure to report such changes will result in the patient being financially responsible for any lapse in coverage or authorization. -I herby authorize F Squared Physical Therapy to release all information necessary to secure payment of benefits. I authorize the use of this signature on all insurance submissions. -I understand it is my responsibility for submitting and following through for reimbursement through my insurance for services rendered by F Squared Physical Therapy when paying for service out of pocket. F Squared Physical Therapy is not held responsible for insurance reimbursement in this situation.BY MY CLICKING "I AGREE" AND SIGNING MY NAME BELOW, I INDICATE THAT I'VE AGREED TO TERMS ABOVE*I agreeI do not agreePLEASE TYPE YOUR NAME BELOW*By typing your name here and signing below, you agree and acknowledge to the stipulations of the form, that all information provided is accurate.Signature* Save and Continue Later Waiver of LiabilityIn agreeing to receive care provided by F Squared Physical Therapy and to use the facilities provided therefore by F Squared Physical Therapy located at 250 West 26th Street Suite 402, New York, New York, 10001 I agree as follows: I fully understand and acknowledge that (a) the activities in which I will engage as part of the treatment provided by F Squared Physical Therapy and the physical therapy activities and equipment I may use as a part of that treatment have inherent risks, dangers, and hazards and such exists in my use of any equipment and my participation in these activities; (b) my participation in such activities and/or use of such equipment may result in injury or illness including, but not limited to bodily injury, disease, strains, fractures, partial and/or total paralysis, death or other ailments that, could cause serious disability; (c) these risks and dangers may be caused by the negligence of the representatives or employees of F Squared Physical Therapy, the negligence of the participants, the negligence of others, accidents, breaches of contract, or other causes. By my participation in these activities and for use of equipment, I hereby assume all risks and dangers and all responsibility for any losses and/or damages whether caused in whole or in part by the negligence or the conduct of the representatives or employees of F Squared Physical Therapy, or by any other person. I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend, and indemnify F Squared Physical Therapy their representatives, employees, and assigns from any and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise out of my use of any equipment or participation in these activities. I specifically understand that I am releasing, discharging, and waiving any claims or actions that I may have presently or in the future for the negligent acts or other conduct by the representatives or employees of F Squared Physical Therapy. I HAVE READ THE ABOVE WAIVER AND RELEASE AND BY SIGNING IT AGREE. IT IS MY INTENTION TO EXEMPT AND RELIEVE F SQUARED PHYSICAL THERAPY FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY NEGLIGENCE OR ANY OTHER CAUSE.*I agreeI do not agreePLEASE TYPE YOUR NAME BELOW*By typing your name here and signing below, you agree and acknowledge to the stipulations of the form, that all information provided is accurate.Signature* Save and Continue Later Cancellation Policy-I acknowledge there is a 24-hour Cancellation Policy and understand that if I do not cancel 24 hours before my scheduled appointment, I accept the responsibility of being charged $100.00. -I understand arriving later then 20 minute after my scheduled appointment time is considered a "no-show" and I will be charged $100.00. -I understand that I will not be seen if I arrive later then 20 minutes after my scheduled appointment. -I understand that I am responsible for my deductible, co-payments, and all late cancellation or no-show fees if applicable. -I understand if i "no-show" to 3 consecutive appointments, my scheduled appointments will be cancelled and I will need to call to make future appointments on a "same-day" basis.BY MY CLICKING "I AGREE" AND SUBMITTING THIS FORM, I INDICATE THAT I'VE AGREED TO ALL TERMS AND CONDITIONS LISTED ABOVE*I agreeI do not agreeYou’re almost done! Once you click on Submit you will be taken to a page where you will need to add a payment method for your co-insurance. Save and Continue Later This iframe contains the logic required to handle AJAX powered Gravity Forms.