Seneca Physical Therapy & Wellness, Inc. in Montgomery County, MD
"Get Fixed, Get Fit, Get Healthy."
   

 

Washington Consumer Checkbook Rankings

Address:
15201 Shady Grove Rd. Suite #106
Rockville, MD 20850

Seneca Physical Therapy - Patient Information Form

Please take a few moments to fill out this form with as much information as possible.  Since you are including sensitive information, be assured that this is sent securely to our offices.  Please do not hesitate to contact us should you have any questions.

Many Thanks!
The Seneca Physical Therapy Staff

Date: Date of Injury/Onset:
Patient Name: Date of Surgery:
Maiden Name: Fax #:
Patient Address: Email Address:
Why did you choose Seneca PT:
Birth Date:
Phone: If Other, please specify:
Cell Phone #:
Marital Status: Referring Physician:
Patient's Age: Primary Care Physician:
Patient's Occupation: Present Medications:  
Patient's Employer:
   

*If the patient is a minor, the parent should provide work information below:

Insurance Company Name:
Identification #
Group #
Insured's Name:
Insured's Employer:
Insured's Employer Address:
Insured's DOB:
Have you had physical therapy in the past for this problem?
IS THIS A WORKER'S COMPENSATION CASE?
If yes, has this claim been accepted?
IS THIS A MOTOR VEHICLE RELATED CLAIM?
If you answered YES to A or B above, please provide the following information
Insurance Co. Name and Address:
Claim #:  Adjustor's Name:  Phone #:
Attorney Name:
Address:

I CERITFY that the information I have given above is correct and I authorize the release of any necessary information to my insurance company.  I permit a copy of this authorization to be used in place of the original and I authorize this signature to be used when processing claims.  I may revoke this in writing at any time.

I HEREBY assign Seneca Physical Therapy, Inc. all payments rendered for my dependent or myself.  If my current policy prohibits direct payment to Seneca Physical Therapy, I hereby instruct and direct my insurance company to make the check payable to me and mail it to Seneca Physical Therapy.  In the event my bill becomes delinquent (over 90 days past due), I understand and agree that I am responsible for paying all charges, including co-payments and coinsurance PLUS finance charges in the amount of 1.5% per month on the unpaid balance, reasonable collection fees and/or attorney fees, and court costs.  In addition, I authorize Seneca Physical Therapy, Inc. to initiate a complaint to the insurance commission for any reason on my behalf.


 

Describe your symptoms:
When did your symptoms first start?
How often do you experience symptoms?
Please choose the word(s) that best describes your symptoms/pain.
Please rate your pain in the last 24 hours
(0 = No pain, 10 = Pain as bad as it can be)
List any activities/positions that INCREASE your symptoms:
List any activities/positions that DECREASE your symptoms:

Medical History

Age:

  years
Weight:  lbs
Have you had treatment for this condition before?
Check ALL of the following health conditions that apply to you:
 
Other Medical Conditions:
Has any immediate family member been treated for any of the conditions listed above?
If Yes, please specify:
Please indicate the number of surgeries for your condition:
Please list your past surgical history with approximate date:
Are you taking prescription medications for this condition?
Are you currently taking any over-the-counter medications, supplements or vitamins?
What test have you had for your symptoms? (Please provide date - if not tested, leave blank)
X-rays   MRI
CT Scan   DEXA Scan
Other 

Social History
How many times a week do you complete at least 20 minutes of exercise?
Please list your exercise/recreational activities:
Occupation:
What is your employment status?

 

   
   
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