Physical Therapy
Intake and Consent Forms
Patient Information
Name
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Age
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Date of Birth
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Month
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Day
Year
Gender/Sex
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Email
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Phone Number
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Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job/Occupation
Parent/Guardian or Emergency Contact Details
Contact Person Name
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Primary Phone Number
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Area Code
Phone Number
Secondary Phone Number
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Area Code
Phone Number
Medical Information
Referring Physician
Date of Injury
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Month
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Day
Year
Date of Surgery
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Month
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Day
Year
Chief Complaint
How did this problem begin?
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Please list any recent diagnostic studies: (X-Ray, MRI, Etc):
Please list any surgeries:
Do you have any limitations/restrictions from your physician:
Upload any relevant documents (prescription, MRI reports, surgical reports, etc.)
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What medications are you currently taking:
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Please specify any allergies:
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Please check any of the following boxes for symptoms/conditions you currently have or have had:
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Bone or Joint Disease
Tendonitis / Bursitis
Arthritis / Gout
Jaw Pain / TMJD
Spinal Problems
Chronic Fatigue
Chronic Pain
Anxiety / Stress Syndrome
Autoimmune Disease
Seizures / Fainting
Heart Conditions
Phlebitis / Varicose Veins
Blood Clots
High / Low Blood Pressure
Lymphedema
Diabetes
Sleep Disorders
Smoking (currently)
Breathing Difficulty / Asthma
Emphysema / COPD
Bladder / Kidney problems
Depression
Migraines / Headaches
Circulatory Problems
None of the Above
Consent of Treatment
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The purpose of physical therapy is to treat disease, injury and disability by examination, evaluation, diagnosis, prognosis, and intervention by use of rehabilitative procedures, mobilization, massage, exercises, and physical agents to aid the patient in achieving their maximum potential within their capabilities and to accelerate convalescence and reduce the length of functional recovery. All procedures will be thoroughly explained to you before you are asked to perform them.Response to physical therapy intervention varies from person to person; hence, it is not possible to accurately predict your response to a specific modality, procedure, or exercise protocol. Physical therapy does not guarantee what your reaction will be to a specific treatment, nor does it guarantee that the treatment will help resolve the condition that you are seeking treatment for.Furthermore, there is a possibility that the physical therapy treatment may result in aggravation of existing symptoms and may cause pain or injury. It is very important to communicate with you treating physical therapist throughout your treatment.It is your right to decline any part of your treatment at any time before or during treatment, should you feel any discomfort or pain or have other unresolved concerns. It is your right to ask your physical therapist about the treatment they have planned based on your individual history, physical therapy diagnosis, symptoms, and examination results. Consequently, it is your right to discuss the potential risks and benefits involved in your treatment.I have read this consent form and understand the risks involved in physical therapy and agree to fully cooperate, participate in all physical therapy procedures, and comply with the established plan of care. I authorize the release of my medical information to appropriate third parties.
I hereby authorize Physical Therapists for Justice and appropriate personnel, to furnish medical care and treatment to me, or the above named patient, considered necessary and proper in diagnosing or treating my/his/her physical condition. (Physical therapists participating in Physical Therapists for Justice include Kathryn Ayoob, Jeanmarie Bante, Symiah Campbell, Tasha Connolly, Chelsea Fan, Erica Harris, Vincent Huynh, Vincent Ho, Trevor Kovacs, Erika Lark, Katie Long, Seth McChesney, Ray Peralta, Kevin Peterson, Reman, Rajab, Julia Rosenthal, Kara Siemer, Kimberly Tjoelker, Allen Torres, Amanda Wirth, Lauren Wittrock, Katie Worrall, Kirstin Wu, and Benjamin Yu)
(ONLY CHECK THIS IF YOU DO NOT HAVE A PRESCRIPTION/REFERRAL) The patient is receiving direct physical therapy treatment services from an individual who is a physical therapist (PT) licensed by the Physical Therapy Board of California. Under California law, the patient may continue to receive direct physical therapy treatment services for a period of up to 45 calendar days or 12 visits, whichever occurs first, after which time a physical therapist may continue providing the patient with physical therapy treatment services only after receiving, from a person holding a physician and surgeon’s certificate issued by the Medical Board of California or by the Osteopathic Medical Board of California, or from a person holding a certificate to practice podiatric medicine from the California Board of Podiatric Medicine and acting within his or her scope of practice, a dated signature on the physical therapist’s plan of care indicating approval of the physical therapist’s plan of care and that an in-person patient examination and evaluation was conducted by the physician and surgeon or podiatrist. With your written authorization, your physical therapist shall notify your physician and surgeon, if any, that he/she is treating the patient.
Patient/Parent/Guardian Signature
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Date Signed
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Month
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Day
Year
How did you hear about us?
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Availability
If you haven't already made an appointment: Please list general availability so we can best accommodate you with a PT (ex. any time after 5PM M-F; only weekends; MWF before 10AM, etc)
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