Your browser does not support JavaScript!
This form cannot automatically check that you have submitted all of the required fields without JavaScript.
Please be sure to submit all required fields (marked with stars).

Bacon County Hospital

Bacon County Rehabilitation Center New Patient

We are delighted that you and your physician chose for us to provide your therapy needs. We strive to provide excellent patient care. In order to get the most from your treatment, we will provide you with your individualized treatment plan, but we need your help for this to be effective.
"Your participation is the most important part of your recovery."
*If you are unable to attend, please call ahead of time to reschedule.
*If more than 3 visits are missed without cause, your physician will be notified and plan for you to be discharged.
*If you are more than 15 minutes late for your appointment, we may have to reschedule.

2. Wear appropriate clothing and shoes needed for therapy.

3. Children are not allowed in the treatment area unless they're being seen.

4. Don't forget to schedule your next appointment before you leave.
New Patient Information Sheet
* Patient's Full Name
* Date of Birth
* Address
* Home Phone
* Cell Phone
* Social Security Number
* Marital Status
* Mother's Maiden Name
* Father's Last Name
* Are you or your spouse emplyed?
  Work Information
Enter the name of your or your spouse's employer.
  Work Address and Phone Number
  E-mail address
* Primary Insurance Carrier
  Secondary Insurance Carrier
  If Medicare is Primary, what is your retirement date?
  If Disabled, what is the date you filed disability?
  And was it work related?
  Referring Physician
  Primary Physician or Provider
  Referring Diagnosis
Emergency Contact
(name, phone number, address, relationship)
* Name
* Relationship to Patient
* Home Phone
* Cell Phone
* Address
* Are you currently in Home Health?
* Are you done with Home Health?
* If you have Medicare Part B, have you had therapy elsewhere this year?
Patient Medical History
  Referring Physician
  Date of next M.D. appointment
History of Current Limitation or Injury
* Date of injury or when problem began
* Briefly describe your problem.
* What could you do before that is difficult now?
* Work Status
* Have you had any of the following tests or procedures for this condition? X-Ray
CT Scan
Bone Scan
  Surgery, if yes, when?
* Rate your pain on a scale from 0 to 10.
(0 = no pain, 10 = need to go to the Emergency Room)
* Please describe the location of your pain.
Past Medical History
* Have you ever been diagnosed with any of the following? Fracture/Dislocation
Respiratory Problems
Blood Clots
High Blood Pressure
Heart Disease
* Please list any surgeries or metal implants you have received.
* Allergies
Please list any allergies.
* Current Medications
Please list any and all medications you are currently taking.