INTAKE FORM
Patient Information
Patient Name
Date of Birth
Today’s Date
Preferred Phone Number
Home
Cell
Email
Mailing Address
City
State
Zip
Occupation
Emergency Contact
Contact Full Name
Relationship to Contact
Contact Phone Number
Home
Cell
By providing my email, cell, landline or any other number(s), you expressly consent to receiving communications from EMG Lab, PLLC, its staff, its contractors, collection agents and others, at any number you provide or that are later acquired for you. Communication may include, but are not limited to phone calls, texts messages and emails.
Patient or Authorized Representative name
Patient or Authorized Representative Signature
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
Medical History: Past and Present
Do you have a history of the following medical conditions?
(check all that apply)
Heart Condition
Artery Disease
Stroke/CVA
Pacemaker
Diabetes
Connective Tissue Disease
Balance or Coordination Issues
High Blood Pressure
High Cholesterol
Thyroid Disorder
Drug Use
HIV / AIDS
Hepatitis
Bleeding Disorders
Chemotherapy
Radiation Therapy
Cancer
Alcoholism
Neuromuscular Junction Disorder
Familiar Neuropathy
Familiar Myopathy
Difficulty Speaking
Difficulty Swallowing
Vision problems
Loss of Taste
Bowel or Bladder Dysfunction
Clotting disorder
Other
Are you pregnant?
Yes
No
Please list past surgeries and dates
Medications
Are you taking any of the following?
Anticoagulants
Acetylcholine esterase inhibitors (pyridostigmine)
Please list all anticoagulants
Please list all acetylcholine esterase inhibitors
Current Status
When did your symptoms begin?
Are your current symptoms the result of an injury, accident or illness?
Yes
No
Approx. date of occurrence
Did your current symptoms develop on their own?
Yes
No
What makes your symptoms better?
What makes your symptoms worse?
Are your symptoms worse at night?
Yes
No
Overall frequency of complaint
Constant 100% of the time
50 to 75% of the time
Intermittent 25 to 50% of the time
25% of the time or less
Rate the severity of your pain on a scale of 0 to 10
(zero is no pain, 10 being the most intense pain you can imagine)
0
1
2
3
4
5
6
7
8
9
10
Have you had an EMG before?
Yes
No
Please bring a copy to your appointment if possible
Hand dominance
Right
Left
Select all symptoms that apply
Numbness
Tingling
Burning
Aching
Pins/Needles
Stabbing
Weakness
Twitching
Cramping
Tremor
Fatigue
Does that get worse with activity?
Yes
No
Additional symptoms
Is there anything else you'd like us to know about your symptoms?
Please indicate on the diagram below where you have your symptoms:
Body Chart
Neck
Neck
Neck
Neck
Back
Back
Shoulder
Shoulder
Shoulder
Shoulder
Elbow
Elbow
Elbow
Elbow
Wrist
Wrist
Wrist
Wrist
Hand
Hand
Hand
Hand
Hip
Hip
Hip
Hip
Knee
Knee
Knee
Knee
Ankle
Ankle
Ankle
Ankle
Foot
Foot
Foot
Foot
Upper Arm
Upper Arm
Upper Arm
Upper Arm
Forearm
Forearm
Forearm
Forearm
Thigh
Thigh
Thigh
Thigh
Calf
Calf
Calf
Calf
EMG Lab Authorization and Consent for Testing
Electromyography (EMG) and Nerve Conduction Testing (NCS) are patient services provided in response to a wide variety of medical conditions for patients of all ages, regardless of gender, color, race, creed, sexual identity, national origin or disability.
The purpose of EMG/NCS testing is to evaluate the neuromuscular system and to find diseases that damage the nerves, muscles or the junctions between the nerves and muscles (neuromuscular junction).
All procedures will be thoroughly explained to you. During the NCS, mild electric currents will be applied to the skin on parts of your body. This is done to assess how quickly impulses travel in nerves and the NCS testing may be repeated on several diJerent nerves. The EMG assesses muscle function. A fine needle electrode will be placed under your skin into the muscle being tested. The needle measures the electrical activity in your muscles and it may be repeated on several muscles. You also will be asked to contract your muscle during the EMG.
There are certain inherent risks with EMG/NCS. During the EMG, you may experience some discomfort similar to an injection and may have some residual soreness and bruising for a few days. EMG may also cause false results on muscle enzyme laboratory test and muscle biopsies. There may also be other risks depending on your medical condition: please discuss those with your referring physician or with your electromyographer. During NCS testing, you may feel a shock like sensation as the nerve is stimulated even though the amount of voltage applied is very small. You may feel your muscles twitch. As with EMG testing, there may be other risk depending on your medical condition; please discuss those with your referring physician or with your electromyographer.
Based on the above information, I agree to cooperate fully and to participate in the procedure. I acknowledge that I have read this authorization and agree to be compliant. I acknowledge that I have had the procedures explained to me.
By signing this form, you do hereby voluntarily consent to such diagnostic procedures and treatment by EMG Lab electrophysiologists or physical therapists as necessary in his/her judgement. You acknowledge that no guarantees have been made to you as to the results of treatment or examination in this laboratory or clinic.
Patient or Authorized Representative name
Patient or Authorized Representative Signature
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Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
Acknowledgement of Receipt of Notice of Privacy Practices for Protected Health Information
Click
HERE
to review EMG Lab's Privacy Policy or for more information about HIPAA compliance click
HERE
.
I acknowledge that I have received EMG Lab’s Notice of Privacy Practices for protected health information.
Patient or Authorized Representative name
Patient or Authorized Representative Signature
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
Acknowledgement of Review of Financial Policies and Procedures
Click
HERE
to review EMG Lab's Financial Policies and Procedures.
I acknowledge that I have reviewed EMG Lab’s Financial Policies and Procedures and that
I HAVE READ, AGREE WITH, AND FULLY UNDERSTAND THIS AGREEMENT
.
Patient name
Beneficiary/Participant
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
Will a parent or party beside the patient be financially responsible?
Yes
No
Name of Person Financially Responsible for Patient’s Treatment
I agree to be appointed and designated as the aforementioned
HIPAA Authorized Representative
, as requested by the above named Beneficiary/Participant, effective as of the date appointed by the aforementioned Beneficiary/Participant.
My name and address is as follows:
Name
Address
City
State
Zip