[Patient] Health Questionnaire & Consent

Health Questionairre & Consent Forms

We are thrilled 💖 you have chosen to partner with us on your healing journey 🙏.

Completing this secure HIPPA protected form prior to your first appointment helps us focus on you and getting you better, faster.

* = required field
PATIENT INFORMATION
Patient Full Legal Name*
Patient Date of Birth*

MonthDayYear
Date
Today Date

MonthDayYear
Date
Age
Address*
Cell Phone Number*
Secondary Phone Number
Email*
Emergency Contact Name *
Emergency Contact Primary Phone Number*
How Did You First Hear About Us*

Healthcare Provider ReferredOnlineFriendOther
Referring Healthcare Provider
Referring Provider's Clinic Name
Online platform

Google SearchGoogle AdFacebook / InstagramOther
Primary Healthcare Care Provider For Symptoms Being Treated (if any)
Gender*

MaleFemaleDecline to Answer
Current Gender Identify
Assigned Birth Sex
Personal Pronoun
Sexual Orientation
Utilizing Health Insurance Benefits?*

YesNo (Cash Pay)
Health Insurance - Group Number
Health Insurance - Member ID
Health Insurance - Phone Number
Please enter a valid phone number.
Do You Have Secondary Insurance?*

YesNo
Secondary Insurance Type*

MedicaidAll others
Secondary Health Insurance - Group Number
Secondary Health Insurance - Member ID
Secondary Health Insurance - Phone Number
Please enter a valid phone number.
Unfortunately, we do not accept patients that have Medicaid as either their primary or secondary insurance and there are no exceptions.

When you have two types of insurance, like Medicare and Medicaid, they must work together to make sure your medical bills get paid. So, when the cost of treatment exceeds what Medicare can pay, which is often the case, then cost sharing policy provisions kick in and we have to bill Medicaid which we don’t accept. We apologize for this inconvenience, and I wish we had better news for you. As a provider it is critical we follow certain insurance rules, otherwise we will almost certainly face legal and financial consequences that would shut the practice.
SYMPTOMS & GOALS:
Primary Health Symptoms*
Primary Therapy Goals
PREGNANCY:
Currently Pregnant?

YesNo
Many Weeks Pregnant?
Important:

Pregnancy:
- 1st trimester: External assessments may be performed if needed, no doctor's note required.
- 2nd and 3rd trimesters: Internal assessments require a doctor's approval or referral.
Postpartum:
- No doctor's note needed.
- Internal assessments are conducted after a minimum 6-week clearance from your OB/GYN or midwife following your postpartum check-up.
On Birth Control?

NoYes, Provide Details (type, name, duration?)
DISCOMFORT FEEDBACK:
What is the pain level range - from least pain (0) to worst pain (10)?
What is the pain level range - from least pain (0) to worst pain (10)?
Describe Pain Type (tick all that apply)

SharpDull / AchyThrobbingShootingNumbness / TinglingConstantIntermittentWorse in AMWeakeningWorse in PMOther
Unexpected Weight Gain or Loss

NoYes - Explain (estimated weight change & period)
Any History of Trauma or Abuse?

NoIf Yes, Explain (Only if Comfortable)
Exercise Habits & Routine? mode, frequency, duration
BLADDER:
Average Daily Fluid Intake (in ounces, as ref. 8fl oz = 1 cup)
Hours Between Emptying Your Bladder During the Day?
Hours Between Emptying Bladder During the Day?
Hours Between Emptying Your Bladder During Night?
Hours Between Emptying Bladder During Night?
Number of Times You Empty During 24 Hour Period?
Number of Times Empty During 24 Hour Period?
Number of Times You Get Up at Night To Empty Your Bladder?
Number of Times Getting Up at Night To Empty Bladder?
BOWEL:
Daily Bowel Movement Frequency?
Daily Bowel Movement Frequency?
Common Stool Consistency (tick all that apply)

LiquidSoftFirmPelletsSelect to Explain Other
Can you fully empty your bowel?

NoYes
Experience pain or discomfort with bowel movements?

NoYes
SEXUAL ACTIVITY:
Experience Pain With Orgasm?

NoYes
Experience Pain With Penetration?

NoYes - explain (initial penetration, deeper penetration and/or certain positions?)
Experience Pain With Erection?

NoYes - explain (pain with ejaculation, penetration and/or certain positions?)
MEDICAL HISTORY:

Check current, previous, or n/a for diagnoses

Other Relevant Medical History
Orthopedic Problems
SURGICAL HISTORY:

Enter Approximate Dates If Applicable. (MM / YYYY)
DIAGNOSTIC TESTS:
List any diagnostic tests associated with symptoms.
Only if easily accessible, upload or bring reports to your treatment session if possible.
Cancelof
MEDICATION & SUPPLEMENT HISTORY:
List all medications, nutritional supplements and over the counter drugs currently taken.
PEDIATRIC PATIENT QUESTIONS:
Evaluation & Treatment History (tick all that apply)

Speech/feeding delayGross motor delayFine motor delayBehavioral/emotional difficultiesLearning DifficultiesAssessed for food sensitivities/allergiesAssessed for breathing difficulties/sleep apneaFamily history of the current conditionCatheterizedOther
List Condition Related Activity Limitations?
Eg. embarrassed to play with friends, can’t go on sleepovers, feels ashamed about leakage and avoids play dates
Minors Feelings As To Severity of Condition?
0= No Problem, 10 = Severest Problem

CONSENT & PRIVACY FORMS:

We strongly encourage you to read these forms as they contain IMPORTANT information about your rights, attestations and financial terms.

You MUST scroll to the bottom of each form to be able to check the box.

* = required field
PARENTAL / GUARDIAN PRESENCE IN MINOR PATIENTS TREATMENT SESSION (patient ages 15-17)*

Consent to treat without parent /guardian present in treatment roomOnly treat in presence of parent /guardian in treatment room
Parent / Guardian Name

First NameLast Name
Voice, Text & Email Appointment Reminders Will Be Sent Unless Preference Below Selected (not required)

TextEmailVoice
Please verify that you are human :)*
Patient Signature (or parent/guardian if patient is under 18 years of age)*

Clear
Date & Time Stamp
Our expert doctorate therapists look forward to seeing you soon and helping get you get back to full health.
Should be Empty:

	Cur.	Pre.	n/a
Bladder Infections
Vaginal Infections
Menopause
Hemorrhoids
Diabetes
Cancer
Osteoporosis
Respiratory Problems
Allergies / Sinusitis
Hormonal Problems
Endometriosis
Prolapse (if known)
Cardiovascular Disease
Thyroid Problems
Cysts / Fibroids
Depression / Anxiety
Digestive Problems
Sexual Diseases
Latex Sensitivity
Neurologic - Brain/Nerve Problem
Vesicoureteral Reflux

	Cur.	Pre.	n/a
Bladder Infections
Prostate Infections
Hemorrhoids
Diabetes
Cancer
Osteoporosis
Respiratory Problems
Allergies / Sinusitis
Cardiovascular Disease
Thyroid Problems
Cysts / Fibroids
Depression / Anxiety
Digestive Problems
Sexual Diseases
Latex Sensitivity
Neurologic - Brain/Nerve Problem
Vesicoureteral Reflux