Oklahoma Hand and Physical Therapy
Please fill out this form prior to your visit.
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Email *
What is your legal name (Last, First, Middle)? *
What is your date of birth? *
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Were you referred by a physician or other healthcare provider? *
What is your current work status? *
How would you rate your overall health? *
Do you use tobacco products? *
Please tell us about your past medical history (any related or seemingly unrelated diagnoses, issues, surgeries, deficiencies, etc). *
Are you currently pregnant or is there a possibility that you could be pregnant? *
Do you currently have or have you had cancer? *
Are you currently taking any prescription AND/OR over-the-counter medications (related or unrelated to the issue you are seeking help for? *
Please list all of your current prescription AND/OR over-the-counter medications. *
Have you had physical therapy this calendar year? *
What issues are you seeking help for from physical therapy? *
Have you seen any other professionals for help with this issue (medical doctor, chiropractor, PT, OT, massage therapist, etc)? *
What testing have you had (X-ray, MRI, CT scan, Urodynamics, etc)? *
Using a 0-10 scale, rate your pain level today (if you are currently having pain). *
Required
Using a 0-10 scale, please rate your pain at its lowest and at its highest in the last 3 days (choose two options). *
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Please tell us what you would like to return to doing that you are currently have difficulty doing do to this issue. Also, include any other goals you would like to achieve? *
Have you recently experienced any of the following (select all that apply)? *
Required
Oklahoma Hand and Physical Therapy Consent to Treat
Please read our Telehealth Consent to Treat policy below.

Telehealth is the delivery of healthcare services using technology when the healthcare provider and member are not in the same physical location. Providers may include primary care practitioners, specialists, and/or subspecialists.
Electronically transmitted information may be used for diagnosis, treatment, follow-up, and/or patient education, and may include any of the following:

• Medical records
• Medical images
• Interactive audio, video, and/or data communications; and/or
• Output data from medical devices, sound and video files

OKHANDPT has interactive electronic systems used within its network. Security software and protocols are employed to protect the confidentiality of patient information and imaging data. Safeguard measures include protecting against intentional or unintentional corruption.
Informed Consent for Telehealth through OKHANDPT.

By signing this form, the patient understands and agrees to the following:

1. The laws that protect the privacy and confidentiality of medical information also apply to telehealth. Information obtained during a telehealth encounter, which identifies the patient, will not be disclosed to any third party without patient's consent except for the purposes of treatment, payment, and healthcare operations.

2. Telehealth may involve electronic communication of patient confidential medical information to other medical providers who may be located in other areas, including out-of-state. Such communication will occur only with the patient's consent.

3. The patient understands that other individuals other than the physical therapist may also be present and may have access to patient's medical information during the consultation in order to operate the video equipment, should such equipment be utilized.

4. The patient understands that some parts of the exam involving physical tests may be conducted by individuals at the patient's location at the direction of the physical therapist.

5. In an emergency consultation, the patient understands that the responsibility of the physical therapist is to advise the patient to seek additional medical advice from a physician or other qualified healthcare practitioner and that the responsibility of the physical therapist will conclude upon the termination of the video conference connection.

6. The patient has the right to withhold or withdraw consent to the use of telehealth during patient care at any time. The patient understands that withdrawing consent will not affect any future care or treatment, nor will it subject the patient to the risk of loss or withdrawal of any health benefits to which the patient is entitled.

7. The patient has the right to inspect all information obtained and recorded during the course of a telehealth interaction and may receive copies of this information. Such inspection and copying of records shall be subject to OKHANDPT office policies and procedures.

8. The patient understands that the patient's condition may require a referral to a specialist for further evaluation and treatment.

I hereby consent to and authorize OKHANDPT to use telehealth in the course of my diagnosis and treatment.
I have read the OKHANDPT Consent to Treat policy and... *
A copy of your responses will be emailed to the address you provided.
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