Sending Medical Form

History of Present Conditions

Pain Drawing

Feel Great
Annoying
Nagging Pain
Hurts even more
Intense Horrible
Unbearable
0 Feel Great
1 - 2 Annnoying
3 - 4 Nagging Pain
5 - 6 Hurts even more
7 - 8 Intense Horrible
9 - 10 Unbearable

Patient Medical Screening Questionnaire

Consent to Evaluate and Treat

I hereby request and consent to the performance of various modes of physical therapy on me (or the patient named below, for who I am legally responsible) by a licensed physical therapist employed by Function Physical Therapy, LLC. I understand as a patient, that Function Physical Therapy, LLC is not liable for any act when providing treatment in accordance of my physical condition. I acknowledge that no guarantee or assurance has been, nor can be, made by Function Physical Therapy, LLC as to the result of the prescribed treatment. By signing this agreement, I confirm that I have read and fully understand this consent form and I understand this consent may be revoked by me at any time

Our Privacy Policy

Function Physical Therapy is committed to upholding the security and confidentiality of personal information that you provide to us. We do not share or sell patient information with anyone outside of our office without your written consent. This covers information including personal, financial or health information.

I understand that under the Health Insurance Portability and Accountability Act (HIPPA) I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to conduct, plan and direct my treatment directly and indirectly, obtain payment from third party payers and conduct normal healthcare operations such as quality assessments and physicians’ certification. I acknowledge that the notice of privacy policies was provided to me to be read and give authorization to Function Physical Therapy, LLC to use and disclose my protected health information for the uses listed to me.

By agreeing below, I have read, or have had read to me, the above consent to evaluation and treatment statement, that I am aware of the privacy policy, and that I certify that me medical information above is correct to the best of my knowledge.