Intake Form | Professional Physical Therapy & Training, LLC

  • New Patient Intake Form

  • If at any point during filling out this form you need to take a break or walk away, we have added a SAVE AND CONTINUE LATER button at the very bottom of the form. We hope this makes filling out our form as convenient as possible. 

  • Patient Information

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  • MD Information 

  • Reason For Visit:

  • Associated Symptoms And Pain Description (Check All That Apply)
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  • Rows
  • Within the past year, have you had any of the following tests? Check all that apply:
  • Have you recently (6 months) noted any new or changes in the following:
  • Please check any of the following healthcare providers who are currently providing you care, or have provided you care in the past 3-6 months:
  • Check any NONPRESCRIPTION MEDICATIONS that you are currently taking:
  • Has anyone in your immediate family (parents / siblings) ever been diagnosed with the following:
  • NECK SECTION 1 - PAIN INTENSITY
  • NECK SECTION 2 - PERSONAL CARE
  • NECK SECTION 3 – LIFTING
  • NECK SECTION 4 – WORK
  • NECK SECTION 5 – HEADACHES
  • NECK SECTION 6 – CONCENTRATION
  • NECK SECTION 7 – SLEEPING
  • NECK SECTION 8 – DRIVING
  • NECK SECTION 9 – READING
  • NECK SECTION 10 – RECREATION
  • Oswestry-Pain Intensity
  • Oswestry-Personal Care (Washing, Dressing, etc.)
  • Oswestry-Lifting
  • Oswestry-Walking
  • Oswestry-Sitting
  • Oswestry-Standing
  • Oswestry-Sleeping
  • Oswestry-Social Life
  • Oswestry-Traveling
  • Oswestry-Employment/Homemaking
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  • WORK MODULE (OPTIONAL)

    The following question ask about the impact of your arm, shoulder or hand problem on your ability to work (including homemaking if that us your main work role).

  • Rows

  • SPORTS/PERFORMING ARTS MODULE (OPTIONAL

    The following question realtes to the impact of your arm, shoulder or hand problem on playing your musical intrument or sport or both. If you play more than one sport or instrument (or play both), please answer with respect to that activity which most important to you.

  • Rows
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  • Section 1 - Communication (Talking)
  • Section 2 - Normal Living Activities (Brushing Teeth/Flossing)
  • Section 3 - Normal Living Activities (Eating, Chewing)
  • Section 4 - Social/Recreational Activities (Singing, Playing Musical Instruments, Cheering, Laughing, Social Activities, Playing Amateur Sports/Hobbies, and Recreation, etc)
  • Section 5 - Non-Specialized Jaw Activities (Yawning, Mouth Opening and Opening my Mouth Wide)
  • Section 6 - Sexual function (Including Kissing, Hugging and Any and All Sexual Activities to Which You Are Accustomed)
  • Section 7 - Sleep (Restful, Nocturnal Sleep Pattern)
  • Section 8 - Effects of Any Form of Treatment, Including, But Not Limited to, Medications, In-office Therapy,Treatment, Oral Orthotics (eg, Splints, Mouthpieces), Ice/Heat, etc.
  • Section 9 - Tinnitus, or Ringing in the Ear(s)
  • Section 10 - Dizziness (Lightheaded, Spinning and/or Balance Disturbance)

  • Your child's health and safety is of the utmost importance to us. In order to have a clear medicial history, development of specific and reasonable goals of treatment as well as a clear understadning of the Plan of Care that the Physical Therapist sets forth, it is required that you attend the initial visit. Special conditions or application of treatment techniques may require parental accompaniment to select or each visit.

    At the intial visit it will be discussed if your pressence is required at susequent treatment visits. Furthermore, for your child to maintain the benefits of treatment between each session, availability for parental communication following treatments is advisable. 

  • The undersigned does hereby authorize Professional Physical Therapy & Training LLC. consent to perform an examination and treatment to the above mentioned minor by employees of Professional Physical Therapy & Training LLC. without a Parent or Guardian present.

  • I, hereby authorize Professional Physical Therapy & Training LLC. To publish photographs and testimonials either taken or provided by my self for educational and training purposes. I understand that the photographs and/or testimonials, including full name and likeness, may be used in Professional Physical Therapy & Training's print, online and video-based marketing materials, as well as other company publications.

  • I hereby release and hold harmless Professional Physical Therapy & Training LLC. from any reasonable expectation of privacy or confidentialitly associated with the above photograph and/or testimonial.

     

    I further acknowledge that my participation is voluntary and I will not receive financial compensation of any kind associated with the taking or publication of these photographs and/or testimonials or participation in Professional Physical Therapy & Training LLC. marketing materials or other publications. I acknowledge and agree that publication of said photograph and/or testimonials confers no rights of ownership or royalities whatsoever.

     

    I hereby release Professional Physical Therapy & Training LLC. its contractors, its employees and any third parties involved in the creation or publication of marketing materials, of liability of claims by me or any third party in my connection in participation.

     

    By signing below I hereby consent to the above and allow Professional Physical Therapy and Training, LLC to use and disclose my health information for purposes of treating me, obtaining payment for services rendered to me, and conducting healthcare operations.

  • I hereby release and hold harmless Professional Physical Therapy & Training LLC. from any reasonable expectation of privacy or confidentialitly associated with the above photograph and/or testimonial.

     

    I further acknowledge that my participation is voluntary and I will not receive financial compensation of any kind associated with the taking or publication of these photographs and/or testimonials or participation in Professional Physical Therapy & Training LLC. marketing materials or other publications. I acknowledge and agree that publication of said photograph and/or testimonials confers no rights of ownership or royalities whatsoever.

     

    I hereby release Professional Physical Therapy & Training LLC. its contractors, its employees and any third parties involved in the creation or publication of marketing materials, of liability of claims by me or any third party in my connection in participation 

     

    By signing below I hereby consent to the above and allow Professional Physical Therapy and Training, LLC to use and disclose my health information for purposes of treating me, obtaining payment for services rendered to me, and conducting healthcare operations.

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