Ginger Fitness and Rehabilitation, Inc
Ginger Fitness and Rehabilitation, Inc
                   We Are Special Because We Care
Exercises on
   

Consultations throughout the state
Call 813-631-9700

Temple Terrace, Central-East Tampa, Brandon
5035 E. Busch Blvd., Ste 7 Tampa, FL 33617

Lakeland Plant City Clinic
1701 South Alexander Street, Suite 111, Plant City, FL 33566

Davis Island Clinic
5 Tampa General Circle, Suite 200, Harbourside Medical Tower, Tampa FL 33606

Westchase,South Tampa, Carrollwood, Town&Country
8455 West Linebaugh Ave Tampa, FL 33625

New Tampa-Wesley Chapel Clinic
27553 Cashford Circle
Wesley Chapel,
FL 33544


Trinity/ New Port Richey
8726 Old County Road 54,
New Port Richey,
FL 34653

NEW PATIENT FORM Prescription Form Picture Gallery Jobs-Internships Volunteer - Students New Hire Paperwork DragonAPS Mobile Site

New Patient Form

Dear Patient / Client,
We are about you.
We take your issues seriously and thoroughly. We comprehensively assess of your pain history, life situations, health and eating habits, etc. Please be patient in filling out this form as thoroughly as you can to help us help you. Skip what you don’t think is relevant.

On our first meeting, please expect that it will take longer, about 1.5 hours for us to get your full information. We will explain in depth as much as we can how we plan to help you. The subsequent visits will be less paperwork and more direct hands-on care.

Come to the sessions with comfortable flexible clothing. You might have to remove part of your clothing if we need to assess the skin, bones, muscles in certain areas. Be ready to remove your shoes and socks as needed. Always let us know if you are uncomfortable with any situation or requests and we will respect your concerns.

Have a nice harmonious day!
Ginger and staff

NOTICE OF [PHI] USE & DISCLOSURE


(*) = Required
Patient Information
(*)   (*)   
Gender: Male       Female
# Exp. Date:
EMPLOYMENT SECTION
Are you here for a Functional Capacity Evaluations?    YES    NO
Purpose of FCE: chose any or all of these:
   To determine general abilities/ limitations
   To qualify for disability
   To match employment - to return to work
Are you here under Workman's Compensation:    YES    NO
  Date started on Workman's Compensation:
  Case Workman's Comp number:
  Case manager First, Last, Phone, Fax:
  Case Management Company:
Employer Name:
Employment Status:
Job title:
Job description:
Last Employer name if not working currently:
What are/were your main tasks:
What are your limitations to working right now:
Emergency Contact 1
First Name:  
Last Name:
Relationship:

Phone Number 1:
Phone Number 2:
Patien'ts main caregiver: Yes / No
Does patient live with this person? Yes / No
Emergency Contact 2
First Name:  
Last Name:
Relationship:

Phone Number 1:
Phone Number 2:
Patien'ts main caregiver: Yes / No
Does patient live with this person? Yes / No
Emergency Contact 3
First Name:  
Last Name:
Relationship:

Phone Number 1:
Phone Number 2:
Patien'ts main caregiver: Yes / No
Does patient live with this person? Yes / No
List of your Physicians
   YES    NO
Primary Care Physician (PCP):
 
Title:
First Name:
Last Name:
Phone:
Fax:
   
Referring Physician:
List of Physicians: Remove  
Specialist:
Title:
First Name:
Last Name:
Name of Group Practice:
Address:
Address2:
City:
State:
Zip:
  Add more
DME Representative:
Name of Representative:
Other not listed:
HOW DID YOU HEAR ABOUT US? CHECK ALL THAT APPLIES







Other Provider:








Please list the website(s) in which you found us:
Did you see our Website at GingerFitness.com or GingerFitnessRehab.com? if so, what did you think of our website:
HEALTH INFORMATION
What is the Medical Condition/Diagnosis that you are most concerned about?
If Spinal Cord Injury, what level? When were these diagnoses made?
Have you had a seizure in the last 6 months? yes         no
If you answered yes, what was the date of the seizure?
Remove
Date of last PHYSICIAN / SPECIALIST VISIT:
What is your reason for visit?
  Add more

Tell me about your pain (including when it started, where, treatment you received)

All the time    Occasionally    Intermittently    No
Please describe your pain the best you can for each body part. Try to analyze your pain to understand how it affects you.
Explain below individually, or if all body parts hurt the same then you can answer just once:
Where are you having pain?
List body part (s): Remove  

From where to where ?
Stays in one place    Spreads out    Moves around    Radiating (to where?)
Sharp Shooting    Aching    Burning    Numbness    Tingling   Discomfort
When did you start having pain in this (these) area (s)?

SEVERITY OF PAIN:
0 NO PAIN 1 2 3 4 5 6 7 8 9 10 WORST pain as if you would need to go to the emergency room
IS YOUR PAIN GETTING:
WORSE BETTER SAME Gets better but would return
WHAT MAKES THE PAIN WORSE:
Movements Changing positions SITTING STANDING WALKING
Bending down Rea