New Patient Paperwork

Back In Motion Physical Therapy and Spine Center

2900 US Highway 12 Suite J Spring Grove, IL 60081 

(815) 675-0699

1. PATIENT INFORMATION

    Marital Status
    May we contact you at work?
    May we leave appt./insurance messages on your answering machine?

    2. INSURANCE INFORMATION

    Is patient covered by additional insurance?

    ASSIGNMENT AND RELEASE

    I certify that I, and/or my dependent(s), have insurance coverage with:

    and assign directly to Back in Motion Physical Therapy and Spine Center and/or its health care providersall insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. 

    The above-named provider may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

    3. PHONE NUMBERS

    IN CASE OF EMERGENCY, CONTACT

    4. ACCIDENT INFORMATION

    Is condition due to an accident?
    Type of accident
    To whom have you made a report of your accident?

    5. PATIENT CONDITION

    Is this condition getting progressively worse?

    Mark an X on the picture where you continue to have pain, numbness, or tingling.

    Mark your Pain Point
    Type of Pain
    Does it interfere with your?
    Activities or movements that are painful to perform

    6. HEALTH HISTORY

    What treatment have you already received for your condition?
    May we contact your primary care provider?
    Place a mark on the checkbox to indicate if you have had any of the following:
    Exercise
    Work Activity
    Habits
    Smoking
    Alcohol
    Coffee/Caffeine Drinks
    High Stress Level
    Are you pregnant?

    Family Medical History 

    Father
    Mother
    Spoue

    7. MEDICATIONS 

    Thank you for taking the time to fill out this form.

    OFFICE HOURS


    Monday
    9:00am - 7:00pm


    Tuesday
    11:00am - 6:00pm


    Wednesday
    9:00am - 7:00pm


    Thursday
    10:00am - 6:00pm


    Friday
    9:00am - 1:00pm


    Saturday & Sunday
    Closed

    Back In Motion Physical Therapy and Spine Center

    2900 US-12 Suite J
    Spring Grove, IL 60081
    P: (815) 675-0699
    F: (815) 675-0689