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 Reaching up Lying down COLD HEAT
Rubbing/ Massage the area Heating ointments Medications
OTHER
WHAT DECREASES THE PAIN:
Movements changing positions SITTING STANDING WALKING
Bending down Reaching up Lying down COLD HEAT
Rubbing/ Massage the areas Heating ointments Medications
OTHER
List another body part
Other explanations about Pain:

List by year (example 2002-8-22: S/P mastectomy, 2004 Total knee replacement, result is still having swelling, or completely healed, no problem)
Year Procedure body part if needed to elaborate, Right or Left side Result of this procedure
Add More
List of Medications: Remove  
Name of Medication:
Dosage in mg
Frequency
Route
Start date:
End date:
List:
Pharmacy Name:
Phone #:
  Add more
Past PT programs: Remove
Clinic name:
Dates of:
Services:
Treatment:
Results:
  Add more

Precautions: Is there anything we need to be careful about while working with you for your safety? Example: heart condition, dizziness, falling, fear, ADHD, lacking attention, distractability, anxiety, hip precautions, fall precautions, wounds, open skin, easy bruising, etc.
HEALTH / MEDICAL
Ht Wt: lb
Cardiovascular/ Pulmonary status (intact/impaired):
Check symptoms you currently have or have had in the past year
GENERAL
Chills
Depression
Dizziness
Fainting
Fever
Forgetfulness
Headache
Loss of sleep
Loss of weight
Nervousness
Numbness
Sweating
MUSCLE/JOINT/BONE
(Pain, weakness, numbness in:)
Arms
Back
Feet
Hands
Hips
Legs
Neck
Shoulders
GENITO-URINARY
Blood in urine
Frequent urination
Lack of bladder control
Painful urination
GASTROINTESTINAL
Appetite poor
Bloating
Bowel changes
Constipation
Diarrhea
Excessive hunger
Excessive thirst
Gas
Hernorrhoids
Indigestion
Nausea
Rectal bleeding
Stomach pain
Vomiting
Vomiting blood
CARDIOVASCULAR
Chest pain
High blood pressure
Irregular heart beat
Low blood pressure
Poor circulation
Rapid heart beat
Swelling of ankles
Varicose veins
EYE, EAR, NOSE, THROAT
Bleeding gums
Blurred vision
Crossed eyes
Difficulty swallowing
Double vision
Earache
Ear discharge
Hay fever
Hoarseness
Lossof hearing
Nosebleeds
Persistent cough
Ringing in ears
Sinus problems
Vision - Flashes
Vision - Halos
SKIN
Bruise easily
Hives
Itching
Change in moies
Rash
Scars
Sore that won't heal
MEN only
Breast lump
Erection difficulties
Lump in testicles
Penis discharge
Sore on penis
Other
WOMEN only
Abnormal Pap Smear
Bleeding between periods
Breast lump
Extreme menstrual pain
Hot flashes
Nipple discharge
Painful intercourse
Vaginal discharge
Other
Date of Last Menstrual Period:
Date of Last Papsmear:
Have you had a Mammogram? Yes       No    Date:
Are you pregnant? Yes       No      Not sure:  
Number of Children:
Check conditions you currently have or have had in the past year
AIDS Alcoholism Anemia Anorexia
Appendicitis Arthritis Asthma Bleeding Disorders
Breast Lump Bronchitis Bulimia Cancer
Cataracts Chemical Dependency Chicken Pox Diabetes
Emphysema Epilepsy Glaucoma Goiter
Gonorrhea Gout Heart Disease Hepatitis
Hernia Herpes High Cholesterol HIV Positive
Kidney Disease Liver Disease Measles Migraine Headaches
Miscarriage Mononucleosis Multiple Sclerosis Mumps
Pacemaker Pneumonia Polio Prostate Problem
Psychiatric Care Rheumatic Fever Scarlet Fever Stroke
Suicide Attempt Thyroid Problems Tonsillitis Tuberculosis
Typhoid Fever Ulcers Vaginal infections Venereal Disease
Frequent Urinary Infections
Others Medical History/problems NOT listed above/ Explanations:
Cognitive


A/Ox3
Sensible conversations
Caution while driving,   wheelchair     Vehicel
Makes good judgment as he drove at day     night.
Works: Full time     Part time     Temporary
LIFESTYLE/ QUALITY OF LIFE
Do you go to school? Yes       No
How many hours/week?
Name of school:
Grade level:
     Day/Week
Special classes/ IEP?
Working toward a degree?
Day / Week

(include any types of exercise, fun activities, exercise styles, or exercise equipment that you use)
DRIVING ABILITY
yes         no
Check box if you are here for a Driving Evaluation and Behind the Wheel/ On the Road Training
Vehicle/Transportation:
Vision
Mobility Skills:
Home Environment:

Do you have any of the following Home Services?

YES ALL NO ALL
1 Home Health Care
2 Home RN (Nurse)
3 Home Health Aides
4 Home Health Therapies (PT, OT, ST)
5 Home IV
6 Diabetes Care
7 Wound Care
8 Colostomy or Supplies Delivered
9 Any Home Equipment Delivery
10 Home Companions
11 Any other services done at home

What would you like to see happen when you work with us?