Medical History Form

Medical History Form

Medical History

Please complete the Medical History Form below.

Name(Required)
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Address
Marital Status(Required)
Employment Status(Required)
Is it OK to Leave Messages?(Required)
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Current Symptoms(Required)
Condition(Required)
Previous Diagnostic or Rehabilitative Services for this (or other) Injury?
Do you have any of the following?
Do you have any of the following? (Cont.)
Are you aware of your diagnosis?(Required)
Are you aware of your prognosis?(Required)
I hereby agree and give my consent to medical treatment in treating my physical condition. I authorize the release of any medical information needed to process my claim. I understand that I am responsible for any charges that are not covered by my insurance carrier. Furthermore, I understand that I am responsible to inform the office of any changes that occur. I authorize the release of payment directly to Optimal Physical Therapy, LLC, regardless of participation in or out-of-network. Should I default on my financial responsibility and collection action is necessary, I will be responsible for collection costs that are incurred.

I acknowledge that I have seen the “Notice of Privacy Practices.” I understand that I may ask questions about the “Notice of Privacy Practices” at any time.

I have read the terms and by signing below I am indicating that I understand the terms.

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“Early treatment is the key to maximizing movement, managing chronic pain and recovering from surgery and injuries.”

Dr. Jennifer Jeschke PT, DPT, CMPT, MFDc

Words from Our Patients

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