Welcome to Ginger Fitness and Rehabilitation, Inc

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
Last Name:() First:() Middle:
DOB:
Gender:	Male Female
SSN:
Dr License: State: # Exp. Date:
Marital Status:
Mailing Address:
Mailing Address #2:
City:
State
Zip code:
Cell Phone:
Home Phone:
Work Phone:
Email:
Employer Name:
Employment Status:

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:

Child Cousin Dad Foster Parent
Friend Grandchild Grandparent Mom
Sibling Spouse Other

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:

Child Cousin Dad Foster Parent
Friend Grandchild Grandparent Mom
Sibling Spouse Other

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:

Child Cousin Dad Foster Parent
Friend Grandchild Grandparent Mom
Sibling Spouse Other

Phone Number 1:

Phone Number 2:

Patien'ts main caregiver:

Yes / No

Does patient live with this person?

Yes / No

List of your Physicians

Do you have a prescription from the Physician? YES NO

Primary Care Physician (PCP):


Title:
First Name:
Last Name:
Name of Group Practice:
Address:
Address2:
City:
State:
Zip:
Phone:
Fax:

Referring Physician: SAME as PCP

List of Physicians: Remove
Specialist:

Title:
First Name:
Last Name:
Name of Group Practice:
Address:
Address2:
City:
State:
Zip:
Phone #:
Fax #:

Add more

DME Representative:
Name of Representative:
Other not listed:

Do you have any of the following Home Services?