J and H New Patient Registration Form

1
Please Indicate Which Johnson & Hayes Clinic You Will Be Visiting* This field is required.
Huntsville, AL: 4240 Balmoral Drive, SW, Suite 100, Huntsville, AL 35801
Madison, AL - Balch Crossing: 8490 Highway 72W, Suite 120, Madison, AL 35758
Madison, AL - Hughes Road South: 97 Hughes Road, Suite P, Madison, AL 35758
Franklin, TN: 740 Cool Springs Blvd., Suite 215, Franklin, TN 37067
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2
Legal Name* This field is required.
Mr.
Prefix
First Name
Middle Name
Last Name
Suffix
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3
Preferred Name
First Name
Last Name
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4
Address:* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
United States
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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5
Home Phone:* This field is required.
Area Code: xxx
Phone Number: xxx-xxxx
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6
Work Phone:
Area Code: xxx
Phone Number: xxx-xxxx
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7
Cell Phone:
Area Code: xxx
Phone Number: xxx-xxxx
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8
Please indicate which phone is primary
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9
E-mail* This field is required.
*For appointment reminders (example@example.com)
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10
Sex
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11
Date of Birth* This field is required.
Date
Year
Month
Day
Date
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12
Social Security NumberOur form is secure
xxx-xx-xxxx
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13
Marital Status
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14
Employer
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15
Occupation
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16
Student?
YESNO
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17
Full-time or Part-time Student?
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18
Emergency Contact Name* This field is required.
Mr.
Prefix
First Name
Last Name
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19
Emergency Contact Phone Number* This field is required.
Area Code: xxx
Phone Number: xxx-xxxx
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20
Emergency Contact Relationship to Patient
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21
How did you hear about Johnson & Hayes Physical Therapists?
Found us online
Friend or Colleague
Doctor Referral
Direct mail
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22
Explain the reason for today's visit* This field is required.
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Ok
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23
Date of Injury or Date Symptoms Began* This field is required.Required for Insurance
Date
Year
Month
Day
Date
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24
If Today's Visit is Post-Op, Date of Surgery
Date
Year
Month
Day
Date
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25
Is Today's Visit Related To or Covered Under Workman's Compensation?
YESNO
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26
Is Today's Visit Related to an Auto Accident?* This field is required.
YESNO
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27
Yes, Today's Visit is Related to an Auto Accident.
In What State Did The Accident Occur?
What is the Date Of The Injury?
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28
Has the Patient had Physical Therapy at Another Facility This Year?* This field is required.
YESNO
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29
Yes, the Patient has had Physical Therapy at Another Facility.
If so, where?
How many visits?
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30
Insurance Company
Insurance Company Name
Policy or Contract Number
Group Number
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31
Is the Patient the Insurance Subscriber?* This field is required.
YESNO
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32
Name of Insurance Subscriber
Mr.
Prefix
First Name
Middle Name
Last Name
Suffix
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33
Relationship of Subscriber to Patient
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34
Subscriber Address
Same as patient address
Different from patient address
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35
Subscriber Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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36
Insurance Subscriber's Sex
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37
Insurance Subscriber's Date of Birth
Date
Year
Month
Day
Date
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38
Insurance Subscriber's Social Security NumberOur forms are secure
xxx-xx-xxxx
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39
Insurance Subscriber's Primary Phone Number
Area Code
Phone Number
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40
Are You a Medicare Patient?* This field is required.
YESNO
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41
Today's Date
Date
Year
Month
Day
Date
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42
Patient Name
Mr.
Prefix
First Name
Middle Name
Last Name
Suffix
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43
Have You Had HOME HEALTH CARE (a medical caregiver of any kind coming to your home) in the Past Twelve Months?
YESNO
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44
What is the Name of the Home Health Agency?
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45
Dates of Home Health Care?
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Ok
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46
Name of Physician Ordering Home Health Care
First Name
Last Name
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47
Patient Name: {legalName}

Date of Birth: {dateOf341}

Occupation: {occupation}

Employer: {employer}
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48
Medical Questionnaire: Today's Date
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49
What Is Your Age?
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50
How Many Hours Per Week Do You Typically Work?
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51
What Problem Or Diagnosis Brings You Here Today?
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52
Side Of Injury?
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53
Date Of Injury
Date
Year
Month
Day
Date
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54
Who Referred You To PT?
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55
Briefly Describe Your Symptoms
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Ok
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56
Describe How Your Condition Or Injury Occurred:
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Ok
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57
Please Rate Your Pain On The Following Scale From 0 to 10.0 = No Pain; 10 = The Worst Pain Imaginable / Emergency Room Pain
Pain At Rest
Pain With Activity
What Is The Frequency Of Your Pain?
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58
Pain At Night?
Does Your Pain Wake You At Night?
If So, How Many Times?
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59
What Eases Your Symptoms?
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60
What Aggravates Your Symptoms?
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61
Are Your Symptoms Getting....
Better
Worse
Same
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62
Is Your Pain Worse In The....
AM
PM
Mid-Day
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63
Work Status
Are You Currently Working?
Are You Currently On?
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64
Is This A Motor Vehicle Claim?
YESNO
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65
What Activities At Home, Work Or Recreational Are You Unable To Perform?
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66
Similar Condition Before?
Have You Had A Similar Condition Before?
If Yes, When?
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67
Test Results For This Condition?
Have you had a test for this condition?
If Yes, when?
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68
Indicate TestsCheck All That Apply (If Applicable)
X-Rays
MRI
Bone Scan
CT Scan
Nerve Conduction Test
Blood Tests
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69
Any Previous Treatment?
Have You Had Any Other Treatment For This Condition?
If Yes, What Kind?
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70
Current Level Of Physical Activity
High
Medium
Low
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71
How Do You Like To Exercise?Separate With A Comma
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72
What Goals Do You Hope To Accomplish With Physical Therapy?
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Ok
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73
Medical History* This field is required.Check Any That Apply
Angina / Chest Pain
Asthma
Arthritis
Blackouts
Blindness
Blood Clot
Blood Clot
Bowel or Bladder Problems
Carpel Tunnel Syndrome
Chest / Abdominal Surgery
Coronary Artery Disease
Cancer
Depression
Diabetes
Diverticulitis
Ear Infections
Endometriosis
Fibroids
Fibromyalgia
Fractures
Frequent Falls
Hearing Problems
Heart Disease
Hepatitis
High Blood Pressure
High Cholesteral
Hypoglycemia
Menopause
Migraine Headaches
Major Spinal Surgery
MRSA
Osteoporosis
Pacemaker / Nitroglycerin
Poor Circulation / Raynaud's
Polio
Seizures
Stroke
TB
Traumatic Injury / MVA
None Of The Above
Scoliosis
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74
Are You Pregnant?
YESNO
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75
History Of Whiplash Or Low Back Pain?
Do You Have A History Of Whiplash Or Low Back Pain?
If So, When / How Long?
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76
Smoke Tobacco?
Do You Smoke Tobacco?
If Yes, How Much?
If Yes, How Long?
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77
List Current MedicationsSeparate each with a comma. You can also choose to bring your medication list with you to your visit.
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78
List Current AllergiesSeparate each with a comma
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79
List All SurgeriesSeparate each with a comma
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80
Signature
Clear
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81
Date & Time Of Signature
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82
Notice of Privacy PracticesSlide your mouse down to the bottom of the window for an option to download the document.
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83
Treatment AuthorizationSlide your mouse down to the bottom of the window for an option to download the document.
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84
I was offered and/or accepted a copy of the privacy policy from Johnson & Hayes Physical Therapists (see previous page)`.

Patient's Name: {legalName}
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85
Guarantor (signature)NOTE: You are the guarantor if you are age 19 and above.
Clear
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86
Date & Time Of Signature
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87
Patient Name: {legalName}

Patient Date of Birth: {dateOf341}

Patient Address: {address4}

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88
I hereby authorize Johnson & Hayes to use and/or disclose certain protected health information (PHI) about me to or for the person or persons listed below:* This field is required.Please consider family or friends with whom you want to share your medical information.
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89
Please describe the specific protected health information you are authorizing Johnson & Hayes to release to the previously listed person or persons:* This field is required.
All Records
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90
This authorization for release of protected health information will expire on the following date:* This field is required.
Never
A Date Of My Choice
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91
This authorization for release of protected health information will expire on the following date:
Date
Year
Month
Day
Date
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92
When my information is used or disclosed as described in this authorization, I understand that it may be subject to disclosure by the persons listed above and may no longer be protected by the federal HIPPA Privacy Rule.

I have the right to revoke this authorization in writing except to the extent that Johnson & Hayes has already acted in accordance with this authorization. My written revocation must be submitted to Johnson & Hayes Privacy Official at 4240 Balmoral Drive, Suite 100, Huntsville, AL 35801.
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93
Signature Of Patient Or Legal Guardian
Clear
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94
Print Name Of Patient Or Legal Guardian* This field is required.
First Name
Last Name
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95
Date & Time Patient Authorization For Release Of Protected Health Information Is Signed.
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96
Tags
[object Object]
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Should be Empty:

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