Welcome to Zarett Rehab & Fitness

Referral & Appointment Details

Patient Personal Information

Sex (Legal)*

MaleFemale

Type of Visit*

InsuranceFitnessWork CompPersonal InjuryAutoD/A

Primary Insurance

Secondary Insurance (Optional)

Additional Details

Authorizations & Policies *

I hereby assign to Zarett Rehab & Fitness all payments made by any insurance company for physical therapy services rendered to myself or my dependents. I have read and agree to the privacy practices and financial policies of Zarett Rehab. I understand that Zarett Rehab has a no show / late cancellation policy. If you do not notify Zarett Rehab with 12 hours notice, you will have to pay a $\$60$ fee for the missed appointment. Date of Signature

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Medical History Intake

1. General Information

2. Medical Conditions Checklist

Please check all that apply:

High blood pressureHeart murmurAtrial fibrillationHeart diseaseHeart attackCirculatory problemsMigraine headachesNeurological problemsCancerLung diseaseBroken bonesMetal implantsOsteoporosisGI problemsStrokeEpilepsy / SeizuresKidney diseaseBowel/bladder changesLiver diseaseAsthmaDiabetes Type 1Diabetes Type 2Dizziness / VertigoDepressionAnxietyNone of them

3. Critical Health Indicators

Do you have a pacemaker?*

YesNo

Females: Are you pregnant?

YesNo

Have you had any falls in the last year?*

YesNo

Have you been hospitalized in the past year?*

YesNo

4. Medications & Procedures

Current Medications Known Allergies

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Part 2: Patient Injury Information

1. Identifying the Issue

Area of Concern (e.g., Lower Back, Right Shoulder)

2. Cause of Symptoms

Is this due to an accident or injury?*

YesNo

3. Diagnostic Tests

Please check any tests you have had for this condition:

MRIX-RayCT ScanEMGMyelogram

Note: Please bring any relevant notes or imaging reports to your appointment.

4. Previous Treatment

Have you ever been treated for the same injury in the past?*

YesNo

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