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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


(*) = Required
Patient Information
(*)
(*)
Gender: Male       Female
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?
PT Diagnoses /codes:
  • General
    • Disorder of muscle, unspecific
    • Fibromyalgia
    • Muscle weakness (generalized)
    • Myalgia
    • Myositis, unspecified
    • Other symptoms and signs involving the musculoskeletal system
  • Neck, Trunk and Back
    • Cervical disc disorder with myelopathy, unspecified cervical region
    • Cervicalgia (pain in cervical neck)
    • Chest pain, unspecified
    • Dorsalgia, unspecified (backache)
    • Low Back Pain
    • Other intervertebral disc degeneration, lumbar region
    • Other intervertebral disc degeneration, lumbosacral region
    • Other intervertebral disc displacement, lumbar region
    • Other intervertebral disc displacement, lumbosacral region
    • Other specified deforming dorsopathies, site unspecified
    • Other specified disorders of temporomandibular joint
    • Pain in thoracic spine
    • Postural kyphosis, site unspecified
    • Temporomandibular joint disorder, unspecified
    • Torticollis
    • Unspecified abdominal pain
    • Unspecified thoracic, thracolumbar and lumbosacral intervertebral disc disorder
  • Shoulder and UE
    • Calcific tendinitis of unspecified shoulder
    • Impingement syndrome of unspecified shoulder
    • Other shoulder lesions, unspecified shoulder
    • Pain in arm, unspecified
    • Pain in L arm
    • Pain in L shoulder
    • Pain in R arm
    • Pain in R shoulder
    • Pain in unspecific limb
    • Pain in unspecified elbow
    • Pain in unspecified finger(s)
    • Pain in unspecified hand
    • Pain in Unspecified shoulder
    • Pain in unspecified wrist
    • Strain of unspecified muscle, fascia and tendon at wrist and hand level, unspecified hand, initial encounter
    • Unspecified sprain of unspecified wrist, initial encounter
  • Hip and LE
    • Pain in L ankle and joints of L foot
    • Pain in L hip
    • Pain in L knee
    • Pain in L leg
    • Pain in leg, unspecified
    • Pain in R ankle and joints of R foot
    • Pain in R hip
    • Pain in R knee
    • Pain in R leg
    • Pain in unspecific limb
    • Pain in unspecified ankle and joints of unspecified foot
    • Pain in unspecified hip
    • Pain in unspecified knee
  • Gait
    • Ataxia, unspecific (poor coordination of limb)
    • Ataxic gait
    • Difficulty in walking, not elsewhere classified
    • Other abnormalities of gait and mobility
    • Paralytic gait
    • Unspecific lack of coordination
    • Unspecified abnormalities of gait and mobility
  • Neurological Disease/Disorders (Peds and Adult)
    • Autistic Disorder
    • Bell's Palsy