J and H New Patient Registration Form

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

Legal Name* This field is required.

Prefix

First Name

Middle Name

Last Name

Suffix

Preferred Name

First Name

Last Name

Address:* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Home Phone:* This field is required.

Area Code: xxx

Phone Number: xxx-xxxx

Work Phone:

Area Code: xxx

Phone Number: xxx-xxxx

Cell Phone:

Area Code: xxx

Phone Number: xxx-xxxx

Please indicate which phone is primary

E-mail* This field is required.

*For appointment reminders (example@example.com)

Date of Birth* This field is required.

Date

Social Security NumberOur form is secure

xxx-xx-xxxx

Marital Status

Full-time or Part-time Student?

Emergency Contact Name* This field is required.

Prefix

First Name

Last Name

Emergency Contact Phone Number* This field is required.

Area Code: xxx

Phone Number: xxx-xxxx

Emergency Contact Relationship to Patient

How did you hear about Johnson & Hayes Physical Therapists?

Found us online

Friend or Colleague

Doctor Referral

Direct mail

Explain the reason for today's visit* This field is required.

Date of Injury or Date Symptoms Began* This field is required.Required for Insurance

Date

If Today's Visit is Post-Op, Date of Surgery

Date

Is Today's Visit Related To or Covered Under Workman's Compensation?

YESNO

Is Today's Visit Related to an Auto Accident?* This field is required.

YESNO

Yes, Today's Visit is Related to an Auto Accident.

In What State Did The Accident Occur?

What is the Date Of The Injury?

Has the Patient had Physical Therapy at Another Facility This Year?* This field is required.

YESNO

Yes, the Patient has had Physical Therapy at Another Facility.

If so, where?

How many visits?

Insurance Company

Insurance Company Name

Policy or Contract Number

Group Number

Is the Patient the Insurance Subscriber?* This field is required.

YESNO

Name of Insurance Subscriber

Prefix

First Name

Middle Name

Last Name

Suffix

Relationship of Subscriber to Patient

Subscriber Address

Same as patient address

Different from patient address

Subscriber Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Insurance Subscriber's Sex

Insurance Subscriber's Date of Birth

Date

Insurance Subscriber's Social Security NumberOur forms are secure

xxx-xx-xxxx

Insurance Subscriber's Primary Phone Number

Area Code

Phone Number

Are You a Medicare Patient?* This field is required.

YESNO

Today's Date

Date

Patient Name

Prefix

First Name

Middle Name

Last Name

Suffix

Have You Had HOME HEALTH CARE (a medical caregiver of any kind coming to your home) in the Past Twelve Months?

YESNO

What is the Name of the Home Health Agency?

Dates of Home Health Care?

Name of Physician Ordering Home Health Care

First Name

Last Name

Patient Name: {legalName}

Date of Birth: {dateOf341}

Occupation: {occupation}

Employer: {employer}

Medical Questionnaire: Today's Date

What Is Your Age?

How Many Hours Per Week Do You Typically Work?

What Problem Or Diagnosis Brings You Here Today?

Side Of Injury?

Date Of Injury

Date

Who Referred You To PT?

Briefly Describe Your Symptoms

Describe How Your Condition Or Injury Occurred:

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?

Pain At Night?

Does Your Pain Wake You At Night?

If So, How Many Times?

What Eases Your Symptoms?

What Aggravates Your Symptoms?

Are Your Symptoms Getting....

Better

Worse

Same

Is Your Pain Worse In The....

Mid-Day

Work Status

Are You Currently Working?

Are You Currently On?

Is This A Motor Vehicle Claim?

YESNO

What Activities At Home, Work Or Recreational Are You Unable To Perform?

Similar Condition Before?

Have You Had A Similar Condition Before?

If Yes, When?

Test Results For This Condition?

Have you had a test for this condition?

If Yes, when?

Indicate TestsCheck All That Apply (If Applicable)

X-Rays

MRI

Bone Scan

CT Scan

Nerve Conduction Test

Blood Tests

Any Previous Treatment?

Have You Had Any Other Treatment For This Condition?

If Yes, What Kind?

Current Level Of Physical Activity

High

Medium

Low

How Do You Like To Exercise?Separate With A Comma

What Goals Do You Hope To Accomplish With Physical Therapy?

Medical History* This field is required.Check Any That Apply

Angina / Chest Pain

Asthma

Arthritis

Blackouts

Blindness

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

Traumatic Injury / MVA

None Of The Above

Scoliosis

Are You Pregnant?

YESNO

History Of Whiplash Or Low Back Pain?

Do You Have A History Of Whiplash Or Low Back Pain?

If So, When / How Long?

Smoke Tobacco?

Do You Smoke Tobacco?

If Yes, How Much?

If Yes, How Long?

List Current MedicationsSeparate each with a comma. You can also choose to bring your medication list with you to your visit.

List Current AllergiesSeparate each with a comma

List All SurgeriesSeparate each with a comma

Date & Time Of Signature

Notice of Privacy PracticesSlide your mouse down to the bottom of the window for an option to download the document.

Treatment AuthorizationSlide your mouse down to the bottom of the window for an option to download the document.

I was offered and/or accepted a copy of the privacy policy from Johnson & Hayes Physical Therapists (see previous page)`.

Patient's Name: {legalName}

Guarantor (signature)NOTE: You are the guarantor if you are age 19 and above.

Clear

Date & Time Of Signature

Patient Name: {legalName}

Patient Date of Birth: {dateOf341}

Patient Address: {address4}

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.

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

This authorization for release of protected health information will expire on the following date:* This field is required.

Never

A Date Of My Choice

This authorization for release of protected health information will expire on the following date:

Date

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.

Signature Of Patient Or Legal Guardian

Clear

Print Name Of Patient Or Legal Guardian* This field is required.

First Name

Last Name

Date & Time Patient Authorization For Release Of Protected Health Information Is Signed.

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