To submit the form, you can send it via email to rehabservices@jerseycitymedical.com, fax it to (555) 123-4567, or drop it off at the Department of Rehabilitation Services, Jersey City Medical Center, 355 Grand St, Jersey City, NJ 07302. Ensure that all fields are completed accurately before submission.

There are no specific important dates for this form in 2024 and 2025. You should complete and submit it during your physical therapy evaluation process.

The purpose of this form is to collect comprehensive medical history and lifestyle information from patients seeking outpatient physical therapy at Jersey City Medical Center. By providing accurate details about their health conditions, medications, living conditions, and pain characteristics, patients enable the medical team to expedite the evaluation process and develop personalized treatment plans. This form ensures that therapists and doctors have all the necessary information to effectively diagnose and treat the patient's condition. Accurate and thorough completion of this form is crucial for the success of the physical therapy program.

• 1. Patient's Name: Enter the full name of the patient.
• 2. Physician: Enter the name of the primary physician.
• 3. Follow up appointment with physician: Provide the date of the next follow-up appointment.
• 4. Age: Enter the patient's age.
• 5. Height: Enter the patient's height.
• 6. Weight: Enter the patient's weight.
• 7. How do you learn best?: Indicate the preferred learning style (verbally, written, visually, demonstration).
• 8. Reason for coming to Physical Therapy: Provide the reason for seeking physical therapy.
• 9. When did your symptoms begin?: Enter the date when the symptoms first appeared.
• 10. Is this resulting from: Circle the appropriate option: Accident, Injury, Recent Surgery, Sudden Onset.
• 11. Diagnostic Tests: Circle the tests that have been performed: X-rays, MRI, CT-Scan.
• 12. Do you have or have you ever had any of the following: Check all health conditions that apply: Diabetes, Heart Attack, Osteoarthritis, etc.
• 13. Are you currently taking any medication?: List any medications taken on a regular basis.
• 14. Have you ever received physical therapy before?: Circle Yes or No, and provide additional details if Yes.
• 15. Living conditions: Check all that apply regarding the patient’s living conditions.
• 16. Occupation: Enter the patient's current occupation.
• 17. Currently working?: Circle Yes or No regarding current employment status.
• 18. Describe any pain: Provide details about the patient's pain using the provided options and scales.
• 19. Pain prevention: Indicate if the pain prevents sleeping or wakes patient up at night.
• 20. Pain impact on activities: List activities that the patient can no longer participate in because of pain.
• 21. Goals for Physical Therapy: Describe the patient’s goals and expectations for physical therapy.
• 22. Markings on body diagrams: Mark the diagrams with specific symptoms such as pain, burning, or tingling.

Failure to submit this form may result in delays or issues with your physical therapy evaluation process at Jersey City Medical Center.

• Evaluation Delays: Without the form, the evaluation process may be delayed as therapists lack necessary information.
• Incomplete Medical History: Important medical history may be missing, affecting the quality of care.
• Inaccurate Treatment Plan: The absence of complete information can lead to less effective treatment planning.

• 1. Initial Consultation: Complete the form before your first appointment to provide detailed medical history.
• 2. Follow-Up Appointments: Update the form as needed for follow-up visits to track progress and any changes in condition.
• 3. Medical Records: Use the form to maintain accurate and up-to-date medical records.