HIPAA
Compliance
Thank you for using our electronic intake!
We know, more boring forms and questionnaires. We will try to make this as painless as possible, (that is our actual job). Most people can complete this in about 10 minutes depending on what you'd like to include, faster if you are on your phone and have autofill. You will have the opportunity to upload your insurance cards, referrals etc. You can save your progress at any time to complete later by clicking the "Save" button below.
There are 4 parts to this intake:
Insurance Information
By providing your health insurance information, we can verify your benefits and give a cost estimation when you show up to your first appointment.
Direct Access for Physical Therapy Services in Illinois
In the state of Illinois, Physical Therapists are able to treat patients without a refferal for 10 visits or 15 business days, which ever limitation is met first. In order to continue treatment after that time period, meaninful and measureable objective improvement must be demonstrated. If no significant improvement is made, we must refer you to a physician to be evaluated. If you do not have a physician, we can help you find one.
Welcome, {preferredName}!
Thank your for choosing Core Physical Therapy! We strive to give our patients the best experience possible while working towards their physical therapy goals. If you ever need anything, please don't hesitate to ask!
We hope you enjoy your time and find us worthy of a 5 star review! (hint, hint...)
Welcome Back, {preferredName}!
Thank your for choosing to come back Core Physical Therapy! It will be great catching up with you from your last tour of duty with us. It is bittersweet, though. In our business, people coming back generally means they aren't feeling so hot. We'd much rather bump into you on the street. We will work hard to get you back up running.
Hmmm... It looks like you selected the "Other" option back where you where asked about what body parts you are seeking treatment. We don't have a questionnaire for that, so you get out of answering questions about that area for now. We will talk about it when you get to the clinic. If you selected other body parts, those questionnaires will follow.
Mid and Low Back Questionnaire
These are standardized questions that are used to help track your progress. We know that not all the questions may pertain to you, but do your best. If you have questions, we can address them when you come to your appointment.
Neck Pain Questionnaire
QuickDASH Questionnaire
Lower Extremity Questionnaire
Pelvic Floor Disability Index
Instructions: Please answer all the questions in the following survey. These questions will ask you if you have certain bowel, bladder, or pelvic symptoms and, if you do, how much they have bothered you over the past 3 months.
PLEASE NOTE: The next page is the signature page. We are aware that some patients are experiencing "hanging" after they sign and hit the submit button. We are still getting your submissions. If you wish to double check, please text us at 773.999.9825.
We are working with the IT team to get this resolved. We apologize for the inconvinience.