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Aquatic Physical Therapy & Beyond, LLC

Patient Information

First Name:   MI:   Last  Name:   Nick Name:  

  Address:    City:       St:                        Zip:
 Phone Home:     Cell:   Work:     Email: 
  Date of Birth
  Soc. Sec.#    Sex

Marital Status:  Married   Widowed   Single   Divorced   Separated
    Employment:     Retired    Full  Time   Part Time  N-None

If you are not the primary insured on any of your insurance policies or you are the Parent and or Guardian of the patient, please complete the following section.  Otherwise, continue to the Emergency Contact Information Section.

Primary Insured       Title:   First Name:    MI:       Last Name:                         
   DOB:    SS#:    Home Phone:     Work:    Cell: 

Emergency Contact Information

  Name of a person to contact in case of an emergency.     Phone Number                  Relationship to patient        Preferred Hospital if any

Insurance Information

  Primary Insurance Co. Name
  Member ID#
  Cust. Service Ph. # (Back of Card)
  Insurance #2 Name
  Member ID#
  Cust. Service Ph. # (Back of Card)
  Insurance #2 Name
  Member ID#
  Cust. Service Ph. # (Back of Card)

Medical Information / Issues

  Do you have a prescription?      Referring Doctor's Name
     Doctor's Phone:  
          Doctor's Fax:  
   Description of the medical issues you are dealing with:  
   If you are dealing with an accident related injury, please complete the following:
   Employment Related:  Yes  No            Accident Related:  Auto   Other  No                    
   Date of first symptom or accident: 
    State the injury took place in:
  Description of the accident / injury :  
By signing below or submitting this form, I authorize the release of any medical or other information necessary to obtain payment from my insurance company or any other third party that is liable for payment for services rendered.   I hereby authorize and direct my insurance company or companies, attorney or any other entity financially covering my treatment at Aquatic Physical Therapy & Beyond, LLC to make direct payment to Aquatic Physical Therapy & Beyond, LLC under any and all applicable coverage, including major medical, for covered charges for services rendered.  I authorize Aquatic Physical Therapy & Beyond, LLC to complain to my insurance(s) company and/or the insurance commission on my behalf.  I also authorize the use of my medical information for managing my health care as well as any related services. In addition, I authorize the use of my medical information for the practiceís health care operations for the purposes of management or administration of the practice and of offering quality health care services.  By signing below I am confirming that I have been given a detailed summary of the NOTICE REGARDING PRIVACY OF PERSONAL HEALTH INFORMATION.
Patient Initials:       Date:     Patient Signature after printing:______________________________


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Aquatic Physical Therapy & Beyond, LLC
Patient Medical History


Name:                                                  Date: 
Do you presently have or have you previously had heart problems? 
          If yes, check all that apply.  
  Heart Attack How Many?    When?
  Chest Pain          Congestive Heart Failure          Abnormal Heart Rate
  Pacemaker Fast Slow Irregular   When?
  Heart Surgery Angioplasty (Balloon)    When?
    By-Pass   When?
              Other  When?
  Other Heart Problems Specify:   
If you presently have or have previously had any of the following conditions, check all that apply
  Asthma          Emphysema          Chronic Obstructive Pulmonary Disease (COPD)
  Shortness of Breath  
  Other Breathing Problems
  Circulatory Problems  
  Back or Neck Problems
               Surgeries and Dates:
       Other Orthopedic Problems
                 Surgeries and Dates:
  High Blood Pressure
  Degenerative Joint Disease (DJD)/Osteoarthitis
  Rheumatoid Arthritis
  Pregnancy (currently)
  Recent Surgeries not mentioned above
         Type:           Date:
Are you allergic to any drugs/medications?    If so, please list below: 
List the medications are you currently taking?
Patient Initials:       Date:     Patient Signature after printing:__________________________
If you use an inhaler, take Nitroglycerine tablets or any other emergency medication please bring it
with you to each appt & let your treating therapist know

Therapist Signature
: ___________________________________________________________


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Aquatic Physical Therapy & Beyond, LLC
Pool and Spa Questionnaire 


1. Are you taking any antibiotics, have any infections or running a fever at this time? 

        If Yes, please list and describe:
2. Do you have bowel or bladder problems? (dribbling, unable to control bowel or bladder?   
       If Yes, please Explain: 
3. Do you have any wounds or open skin areas? 
      If Yes, please Explain: 
4. Do you have any bandages or dressings at this time? 
      If Yes, please Explain: 
5. Do you have any tubes? (Example: feeding tube, catheter, GI tube) 
      If Yes, please Explain: 
6. Do you have any rashes? 
      If Yes, please Explain: 
7. Do you have normal blood pressure? 
      If No, please Explain: 
PLEASE NOTE: If during the course of your therapy, you develop ANY of these symptoms,
YOU MUST let your  therapist know BEFORE you enter the pool/hot tub.  It is URGENT that
these symptoms be addressed before you enter the pool for your safety as well as the other patientís.
Swim or Float:
     I can swim.
     I don't swim, but I like the water.
     1 don't like the water, but I'm willing to try.
     I want a therapist in the pool with me.
To enter the Pool:
     I need the chair lift.
     I need help with the stairs.
     I can enter the ool on my own.
Water Chemistry:
     I have never reacted to chlorine before.
     I am allergic to chlorine.
     I have been in a pool before.
     I have never been in a pool.
     I have been in a hot tub before.
     I have never been in a hot tub.
To Get Ready for the Pool:
     I will bring my own help for changing.
     I do not need help changing.
Hot Tub Heat - 100+ temperature.
     I am fine with heat.
     I son't do well with heat

I have read and understand this form. I agree to abide by the rules of the pool usage. I have  been given the
opportunity to ask questions and understand that I may ask questions at any time if I am not sure about something.

Patient Initials:       Date:     Patient Signature after printing:_________________________

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Aquatic Physical Therapy & Beyond, LLC
Patient Responsibilities

8305 Falls of Neuse Rd, Suite 102 Raleigh, NC 27615 Phone # 919-870-4444 Fax # 919-870-4447

Patient Responsibilities

 We provide the best physical therapy in the triangle region.  We are only able to do this if our patients agree to and comply with the below patient responsibilities:                                                                                                                                                                               

1)       You agree to show up on time, dressed for the right environment (gym/pool) and at the right hour.

When you are late, show for the wrong environment or come at the wrong hour, we are forced to handle a patient load that we did not anticipate.  This hurts not only your care, but other patientsí care as well.  First of all, you donít receive the direct care we anticipated giving you.  Secondly, the other patients who are here when you show up do not get the direct care that they were scheduled for.  Lastly, we stress trying to give everyone the same excellent service despite the difficult circumstances.

2)       You agree to comply with your treatment plan as prescribed by your physical therapist, including

a.       Showing up for all of your visits each week

b.       Showing up ready for the right environment.

c.        Performing your home exercises as prescribed to you.

d.       Performing &/or adjusting any other daily or nightly activities that you are asked to alter. 

We have had amazing success with our patients due to the fact that they comply with their treatment plan, show for their visits and come ready for the right environment.  If you have any concerns, time or financial restrictions, please bring them to our attention, so that we can figure out how to handle the situation.  We will work with you to help you integrate physical therapy into your lifeís schedule, so that we can resolve your issue.

The front office is only responsible for collecting moneys due to the clinic and scheduling the patients as instructed to do so by the caregivers on your checkout sheet.   They cannot change treatment plans, including the number of visits per week that you attend, the number of weeks planned for your treatment or even the environments that you are to be treated in for each visit.  All such questions must be directed to your caregivers.  If you are forced to cancel one of your prescribed visits and you are not able to set a makeup for a different day of that week, it is your responsibility to relay this to your CAREGIVER as well as the front office.  

By signing below, you are stating that all your questions have been answered, so that you completely understand what is expected of you during your treatment at our facility.  By signing below you are also declaring that you understand that your physical therapist may conclude your treatment at our facility at any point in time if you do not comply with all the responsibilities enveloped within this agreement. \ 

Patient Initials:       Date:     Patient Signature after printing:_________________________________________

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