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Alliance Therapy Services |
| Admit/Medical History Form - Page 1 |
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Patient Name:__________________________ DOB:___________ E-Mail Address:_________________
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Home Address:__________________________________ City:_______________ State:___ Zip:______
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Home Phone:______________ Work:______________ Cell:______________ Sex:___ Marital Status:_
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DL#:_____________ SS#:______________ Date of Injury:___________ Area of Pain:_____________
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Insured's Name:___________________________________________ Insured's Date of Birth:______________
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Referring Physician:______________ Primary Care Physician:______________ Next Phys. Visit:______
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Place of Employment:________________________________ Job Title:__________________________
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Explain how injury occurred:____________________________________________________________
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Any medical conditions that warrant Special Attention?:____________________________________________
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Have you attended outpatient physical therapy/occupational/speech therapy this year?____yes ____no
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| Are you currently receiving home health services? _____yes _____no |
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In case of emergency, notify:____________________ Relationship:___________ Phone:___________
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Do you have an attorney representing you for this injury?_______yes ________no
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I understand that I will be charged 1.5% interest (monthly) on all balances (deductibles, co-pays, co-insurance, and non-covered charges) that are not paid by my insurance carrier/attorney/or third party carrier, and that is owed by me by 30 days after discharge. If for any reason an amount is turned over to a collection agency, there will be a fee of $25.00 in addition to the balance of the account.
Date:_________________ Signature:__________________________________
____________________________________________________________________________________________
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Past Medical History
Please indicate whether you have had any of the following conditions:
Heart disease or heart attack............ [ ]Yes [ ]No Stroke...........................................[ ] Yes [ ] No
Epilepsy or convulsions...................... [ ]Yes [ ]No Diabetes.......................................[ ] Yes [ ] No
Tumor or cancer............................... [ ]Yes [ ]No Respiratory disease........................[ ] Yes [ ] No
Tuberculosis..................................... [ ]Yes [ ]No Asthma.........................................[ ] Yes [ ] No
Hepatitis.......................................... [ ]Yes [ ]No Hernia..........................................[ ] Yes [ ] No
Venereal disease.............................. [ ]Yes [ ]No Are you now pregnant?...................[ ] Yes [ ] No
Congenital abnormalities.................... [ ]Yes [ ]No Respiratory disease........................[ ] Yes [ ] No
Anemia or other blood disorder........... [ ]Yes [ ]No Do you have any surgical implants?..[ ] Yes [ ] No
Bleeding disorders............................. [ ]Yes [ ]No
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