FORMS - Restore Physical Therapy is now Orthology

1 SECTION 4 - FORMS ?PT/OT Intake ..1?Outcomes ..2?PT/OT Treatment (TX) form ..3?Advanced Review form (need description)..4?Claim Grievance Appeal & Grievance form ..6 FORMSPT/OT Intake FormVersion (July 20, 2009) planMember IDFirst nameDate Date of birth1. Why are you here today? If there are many reasons, please check only the most important problem. Neck Mid-back Lower back Headache Shoulder Elbow Wrist Hand Hip Knee Ankle Foot Cardiac Stroke Spinal cord Post-surgery Wound care/burns Balance/coordination Pelvis/incontinence Other injury/illness2. When did this problem first begin?Check Box <1 week ago 1-6 weeks ago 7-12 weeks ago 3-12 months ago >12 months agoPlease answer each of the following questions with a "yes" or "no".NoYes3Is this problem related to a work injury?

2 4Is this problem related to a motor vehicle accident?5 Have you ever had this problem in the past?6 Have you ever had diagnostic testing such as x-rays or MRI for this problem?7 Does this problem generally get worse with movement or activity?8 Does this problem generally get better with rest?Please answer each of the following questions with a "yes" or "no".NoYes9Do you currently feel weakness in both your arms that makes lifting them difficult?10Do you currently feel weakness in both your legs that makes walking difficult?11Do you currently have any numbness in your groin area, genitals, or buttocks?12 Have you recently noticed a lot of problems with your balance (falling or knocking into things)?13 Have you recently had difficulty controlling your bowel movements?

3 14 Have you recently had difficulty controlling your urine or been unable to urinate?15 Have you recently had a lot of difficulty remembering where you are?16 Have you recently had a lot of visual problems such as blurred or double vision?17 Have you recently felt dizzy, faint, or light-headed a lot?18 Have you recently felt a lot of pain in your chest?19 Have you recently felt a lot of shortness of breath?20 Have you recently noticed that your heart is beating a lot more rapidly than normal?21 Have you recently been coughing up a lot of blood?22Do you currently have a weakened immune system?23 Have you ever used any injected drugs (non-prescription)?24Do you currently have a severe fever or chills?25 Have you recently been sweating a lot more than usual?

4 26 Have you recently had any type of infection?27 Have you recently had any type of surgery or surgical procedure?28 Are currently taking any blood thinner medication (Coumadin, heparin, daily aspirin)?29 Have you recently felt that one leg was a lot warmer than the other?30 Have you recently noticed a lot of swelling or severe skin color changes in one or both legs?31 Have you ever been diagnosed with osteoporosis (weak, soft, or brittle bones)?32 Have you ever used steroids such as prednisone for more than 4 weeks?33 Have you recently had any other any other type of accident (falling from a height)?34 Have you ever been diagnosed with cancer?35 Have you recently lost a lot of weight without trying to?If you answered "yes" to any of the questions in the section immediately above (numbers 9-35):NoYes36 Were you recently given the OK by a medical doctor to receive Physical or occupational Therapy ?

5 Last nameOutcomes FormVersion (July 15, 2009) each of the following 12 questions, please mark an "X" in the one box that best describes general, would you say your health isExcellentVery goodGoodFairPoorThe following questions are about activities you might do during a typical your health now limit you in these activities? If so, how much?Yes,limiteda lotYes,limiteda littleNo, notlimitedat all2 Moderate activities, such as moving a table, pushinga vacuum cleaner, bowling, or playing golf3 Climbing several flights of stairsDuring thepast week, how much of the time have you had any of the following problems with your work or other regulardaily activities as a result of your Physical health?Allofthe timeMost ofthe timeSome ofthe timeA little ofthe timeNone ofthe time4 Accomplished less than you would like5 Were limited in the kind of work or other activitiesDuring thepast week, how much of the time have you had any of the following problems with your work or other regulardaily activities as a result of any emotional problems (such as feeling depressed or anxious)?

6 Allofthe timeMost ofthe timeSome ofthe timeA little ofthe timeNone ofthe time6 Accomplished less than you would like7 Did work or other activities less carefully than usual8 During thepast week, how much did pain interferewith your normal work (including both work outsidethe home and housework)?Not at allA little bitModeratelyQuite a bitExtremelyThese questions are about how you feel and how things have been with you during thepast each question, please give the one answer that comes closest to the way you have been much of the time during thepast timeMost ofthe timeSome ofthe timeA little ofthe timeNone ofthe time9 Have you felt calm and peaceful?10 Did you have a lot of energy?11 Have you felt downhearted and depressed?12 During thepast week, how much of the time has yourphysical health or emotional problems interfered withyour social activities (like visiting friends, relatives,etc.)

7 ?All ofthe timeMost ofthe timeSome ofthe timeA little ofthe timeNone ofthe timePlease mark an "X" in the one box that best describes the severity of your main problem for each timepoint:Time point0123456789 1013 Right nowNot severeWorst possible14On averageNot severeWorst possible15At its bestNot severeWorst possible16At its worstNot severeWorst possibleLast nameInsurance planMember IDFirst nameDate Date of birthPT/OT Treatment FormVersion (August 4, 2009) A. Provider informationSpecialtyPhysical therapyOccupational therapyFirst nameTax ID--Last nameNPI--PhoneFax--Practice nameAddressNumberStreetCityStateZipSecti on B. Patient informationFirst nameGenderFemaleMaleLast nameDate of birth M M D D Y Y Y YSection C. Insurance informationCheckifWorker's compensationCheckifNo-fault insuranceSection D.

8 Referring physician information (if applicable)Date of examinationDate of prescriptionSection E. Date informationDate of injury/illness/surgeryDate of last visitDate of first visitRequested visit startSection F. Primary region of complaint (select onlyone)SpineUpper extremityLower extremityRehabilitationOtherCervicalShou lderLRHipLRCardiacWound care/burnsC/S+radiculopathyElbowLRKneeLR StrokeBalance/coordinationThoracicWristL RAnkleLRSpinal cordPelvis/incontinenceLumbosacralHandLR FootLRPost-surgicalOther illness/injuryL/S+radiculopathyDevelopme ntalCancerDiagnosis for primary region of complaint ( ICD-9 code orapproved corresponding text description):Section G. Red flagsDoes this patient have any red flags indicative of potentially serious pathology?

9 NoYesIf yes, is this a contraindication to receiving PT/OT care from you for this complaint?NoYesNot applicableSection H. EvaluationBased on information provided by the patient, your examination, and your treatment history with this patient (if any),what is your evaluation of this patient's primary region of complaint? Please checkone box for each of these mildVery goodNoneVery goodMildGoodVery fewGoodModerateModerateFewModerateSevere PoorManyPoorVery severeVery poorVery manyVery poorSection I. Treatment Supervised exerciseEducationHome exerciseModalitiesManual therapyOtherNumber of PT/OT visits for primary region of complaint since last PT/OT Treatment form was submittedProvider signatureDateCompleting and signing this form indicates that the provider:1.

10 Provided/supervised all PT/OT services, and2. is a participating PT/OT provider, and3. provided all PT/OT services in a credentialed nameLast nameHealth PlanMember IDStevenBraverman212-594-6054 Steven L. Braverman, PT PC450 Seventh Avenue, New York, NY 10123PT/OT Advanced Treatment FormVersion (July 30, 2009) signatureDateCompleting and signing this form indicates that the provider:1. provided/supervised all PT/OT services, and2. is a participating PT/OT provider, and3. provided all PT/OT services in a credentialed A. Provider informationFirst nameNPILast nameTelephoneSection B. Patient informationFirst nameMember IDLast nameDate of birthSection C. Advanced evaluationPlease indicate the specific symptoms, functional limitations, co-morbidities, and prognostic indicators on which youbased your evaluation of these factors in this patient on the PT/OT Treatment form .