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
2
Legal Name* This field is required.
Mr.
Mr.
Mrs.
Ms.
Miss
Prefix
First Name
Middle Name
Last Name
Suffix
3
Preferred Name
First Name
Last Name
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
Curacao
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
5
Home Phone:* This field is required.
Area Code: xxx
Phone Number: xxx-xxxx
6
Work Phone:
Area Code: xxx
Phone Number: xxx-xxxx
7
Cell Phone:
Area Code: xxx
Phone Number: xxx-xxxx
8
Please indicate which phone is primary
Home Phone
Work Phone
Cell Phone
9
E-mail* This field is required.
*For appointment reminders (example@example.com)
10
Sex
Male
Female
11
Date of Birth* This field is required.
Date
Year
Month
Day
12
Social Security NumberOur form is secure
xxx-xx-xxxx
13
Marital Status
Married
Single
14
Employer
15
Occupation
16
Student?
YESNO
17
Full-time or Part-time Student?
Full-time
Part-time
18
Emergency Contact Name* This field is required.
Mr.
Mr.
Mrs.
Ms.
Miss
Prefix
First Name
Last Name
19
Emergency Contact Phone Number* This field is required.
Area Code: xxx
Phone Number: xxx-xxxx
20
Emergency Contact Relationship to Patient* This field is required.
21
How did you hear about Johnson & Hayes Physical Therapists?* This field is required.Please choose the option that influenced you the most.
Advertisement at Local Business
Attended Clinic Workshop
Community Event
Direct Mail
Doctor Referral
Drive By
Facebook
Family/Friend
Google/Internet Search
I am a Friend of a Clinic Employee
I am a Friend of a Clinic Owner(s)
Insurance Company Referral
News/Newspaper/Magazine Article
Newspaper/Magazine Advertisement
Other Social Media Channel
Previous Patient
Radio Advertisement
Television Advertisement
None of the Above
22
Explain the reason for today's visit* This field is required.
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Large
Normal
Small
Ok
Ok
23
Date of Injury or Date Symptoms Began* This field is required.Required for Insurance
Date
Year
Month
Day
24
If Today's Visit is Post-Op, Date of Surgery
Date
Year
Month
Day
25
Is Today's Visit Related To or Covered Under Workman's Compensation?
YESNO
26
Is Today's Visit Related to an Auto Accident?* This field is required.
YESNO
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?
28
Has the Patient had Physical Therapy at Another Facility This Year?* This field is required.
YESNO
29
Yes, the Patient has had Physical Therapy at Another Facility.
If so, where?
How many visits?
30
Primary Insurance Company
Insurance Company Name
Policy or Contract Number
Group Number
31
Would you like to provide information for a Secondary Insurance?* This field is required.
YESNO
32
Secondary Insurance Company
Insurance Company Name
Policy or Contract Number
Group Number
33
Is the Patient the Insurance Subscriber?* This field is required.
YESNO
34
Name of Insurance Subscriber
Mr.
Mr.
Mrs.
Miss
Ms.
Prefix
First Name
Middle Name
Last Name
Suffix
35
Relationship of Subscriber to Patient
Spouse
Mother
Father
Guardian
Other
36
Subscriber Address
Same as patient address
Different from patient address
37
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
Curacao
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
38
Insurance Subscriber's Sex
Male
Female
39
Insurance Subscriber's Date of Birth
Date
Year
Month
Day
40
Insurance Subscriber's Social Security NumberOur forms are secure
xxx-xx-xxxx
41
Insurance Subscriber's Primary Phone Number
Area Code
Phone Number
42
Are You a Medicare Patient?* This field is required.
YESNO
43
Today's Date
Date
Year
Month
Day
44
Patient Name
Mr.
Mr.
Mrs.
Miss
Ms.
Prefix
First Name
Middle Name
Last Name
Suffix
45
Have You Had HOME HEALTH CARE (a medical caregiver of any kind coming to your home) in the Past Twelve Months?
YESNO
46
What is the Name of the Home Health Agency?
47
Dates of Home Health Care?
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Ok
48
Name of Physician Ordering Home Health Care
First Name
Last Name
49
Patient Name: {legalName}

Date of Birth: {dateOf341}

Occupation: {occupation}

Employer: {employer}
50
Medical Questionnaire: Today's Date
51
What Is Your Age?
52
How Many Hours Per Week Do You Typically Work?
53
What Problem Or Diagnosis Brings You Here Today?
54
Side Of Injury?
Left
Right
55
Date Of Injury
Date
Year
Month
Day
56
Who Referred You To PT?
57
Briefly Describe Your Symptoms
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Small
Ok
Ok
58
Describe How Your Condition Or Injury Occurred:
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Small
Ok
Ok
59
Please Rate Your Pain On The Following Scale From 0 to 10.0 = No Pain; 10 = The Worst Pain Imaginable / Emergency Room Pain
0
1
2
3
4
5
6
7
8
9
10
Pain At Rest
0
1
2
3
4
5
6
7
8
9
10
Pain With Activity
Constant
Intermittent
What Is The Frequency Of Your Pain?
60
Pain At Night?
Yes
No
Does Your Pain Wake You At Night?
If So, How Many Times?
61
What Eases Your Symptoms?
62
What Aggravates Your Symptoms?
63
Are Your Symptoms Getting....
Better
Worse
Same
64
Is Your Pain Worse In The....
AM
PM
Mid-Day
65
Work Status
Yes
No
Are You Currently Working?
Light Duty
Normal Duty
Are You Currently On?
66
Is This A Motor Vehicle Claim?
YESNO
67
What Activities At Home, Work Or Recreational Are You Unable To Perform?
68
Similar Condition Before?
Yes
No
Have You Had A Similar Condition Before?
If Yes, When?
69
Test Results For This Condition?
Yes
No
Have you had a test for this condition?
If Yes, when?
70
Indicate TestsCheck All That Apply (If Applicable)
X-Rays
MRI
Bone Scan
CT Scan
Nerve Conduction Test
Blood Tests
71
Any Previous Treatment?
Yes
No
Have You Had Any Other Treatment For This Condition?
PT
OT
Chiropractic
Massage
Other
If Yes, What Kind?
72
Current Level Of Physical Activity
High
Medium
Low
73
How Do You Like To Exercise?Separate With A Comma
74
What Goals Do You Hope To Accomplish With Physical Therapy?
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Ok
Ok
75
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
76
Are You Pregnant?
YESNO
77
History Of Whiplash Or Low Back Pain?
Yes
No
Do You Have A History Of Whiplash Or Low Back Pain?
If So, When / How Long?
78
Smoke Tobacco?
Yes
No
Do You Smoke Tobacco?
If Yes, How Much?
If Yes, How Long?
79
List Current MedicationsSeparate each with a comma. You can also choose to bring your medication list with you to your visit.
80
List Current AllergiesSeparate each with a comma
81
List All SurgeriesSeparate each with a comma
82
Signature
Clear
83
Date & Time Of Signature
84
Notice of Privacy PracticesSlide your mouse down to the bottom of the window for an option to download the document.
85
Treatment AuthorizationSlide your mouse down to the bottom of the window for an option to download the document.
86
I was offered and/or accepted a copy of the privacy policy from Johnson & Hayes Physical Therapists (see previous page)`.

Patient's Name: {legalName}
87
Guarantor (signature)NOTE: You are the guarantor if you are age 19 and above.
Clear
88
Date & Time Of Signature
89
Patient Name: {legalName}

Patient Date of Birth: {dateOf341}

Patient Address: {address4}
90
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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Small
Ok
Ok
91
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
92
This authorization for release of protected health information will expire on the following date:* This field is required.
Never
A Date Of My Choice
93
This authorization for release of protected health information will expire on the following date:
Date
Year
Month
Day
94
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.
95
Signature Of Patient Or Legal Guardian
Clear
96
Print Name Of Patient Or Legal Guardian* This field is required.
First Name
Last Name
97
Date & Time Patient Authorization For Release Of Protected Health Information Is Signed.
98
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