Physical Therapy Intake Form

Physical Therapy Intake Form

Please complete prior to your initial evaluation
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Post CodeCountry
E-mail*
Phone Number*

Area CodePhone Number
Date of Birth*

DayMonthYear
Gender/Pronouns
Who should we thank for this referral?
Please include email and phone if you have.
Primary Care Physician
Please include email and phone if you have.
Physician Email (if known)
example@example.com
Other health practitioners you see
Please provide: Name, Specialty, Conditions addressed, Phone number
Please list each condition that brings you here, in order of importance
Please include DATE OF ONSET and CAUSE
What provides you relief or improvement?
In general, how is your quality of life affected by the condition(s}/ situations(s) listed above?
If you could change or improve one aspect of your health, what would it be?
What type(s) of exercise do you do?
Have you ever participated in a yoga practice, formally or informally?

YesNo
Are you interested in learning how to integrate an appropriate level of yoga with your therapeutic program?

YesNo
What activities do you find nourishing to your soul?
Who or what do you have as a support system?
Have you ever had surgery?

YesNo
Please provide details/dates
Do you have any concerns with your digestion?

YesNo
Please provide details
Do you have any concerns with your sleep?

YesNo
Please provide details
Are you interested in possible options for natural remedies?

YesNo
Are you presently taking any medications?

YesNo
If yes, please list name, for what condition and how long.
Do you have concerns about the side effects of the medications you are taking?

YesNo
During the past month, have you been bothered by having little interest or pleasure in doing things?

YesNo
I take medication that sometimes makes me feel lightheaded or feel more tired than usual.

YesNo
I need to push with my hands to stand up from a chair.

YesNo
Sometimes I feel unsteady when I am walking.

YesNo
I have lost some feeling in my feet.

YesNo
I am worried about falling.

YesNo
Have you fallen in the last year?

YesNo
Is there anything else about either your history or your current condition that you feel is important to mention?
Please check any condition you have had in the last 12 months.
MUSCLE/SKELETAL

Bone/Joint diseaseTendonitisSprains/StrainsArthritisBroken/Fractured bonesLow back, hip, or leg painNeck, shoulder, or arm painHeadache, migraine, head injurySpasms/CrampsJaw pain/TMJLupusDental problemsWeakness
CIRCULATORY

Heart condition/diseaseBlood ClotsVaricose veinsHigh/Low blood pressureArteriosclerosisLymphedemaBruises easilySwollen anklesStroke
DIGESTIVE

Recurrent indigestionConstipationGas/bloatingIBSLoose bowelsDiverticulitis
NERVOUS

Numbness/tinglingChronic painHerpes/ShinglesFatigueSleep disordersNervousness
RESPIRATORY

TuberculosisAsthmaChronic bronchitisEmphysemaBreathing difficultyAllergiesSinus issues
REPRODUCTIVE

Irregular/Heavy/Light periodHeightened PMSAbnormal bleedingNon menstrual pelvic painPregnancy
SKIN

AllergiesRashes
OTHER

Cancer/TumorsLiver diseaseDiabetesEating disorderDepressionDrug/Alcohol addictionNicotine/Caffeine addictionLack of coordinationDizziness/VertigoUrinary disorderChest pain

- APPOINTMENTS- We commit a full 50 minutes to each client’s session. Starting and ending on time allows each person to have their full appointment time and allows your therapist to prepare for the next session. If you are late for a session,you may lose some of that session time. We appreciate your understanding.
- SELF PAY PRICING (As of March 1, 2020)- Initial Appointment: In Person- $150; Telehealth- $110; Follow up Appointments: In Person- $130; Telehealth- $90
- INSURANCE- *We are IN NETWORK with BCBS which covers many but NOT ALL BCBS plans, for example some of those associated with Duke and UNC are not in network. *We are IN NETWORK with Traditional Medicare. We can file insurance for those with Medicare Advantage plans, (although we are not in network with these plans). We will also file secondary insurance. *We are OUT-OF-NETWORK with all other primary insurances. We require payment of our full fee at the time of service, but we are happy to provide you with a Superbill (upon request) to submit to your insurance company for possible reimbursement/application to your out-of-network deductible.
A $30 service charge will be charged for any returned checks.
- CANCELLATION PROCEDURE & POLICY -If you find you must cancel, please call the office as soon as possible, and at least 24 hours in advance of your appointment time. This will allow your therapist to utilize that time slot by giving another person access to it. If you are unable to cancel within 24 hours notice, you are responsible for a $45 late cancellation fee which will be automatically charged to your account.
- PAYMENT AUTHORIZATION- I authorize Wellness Station to charge balances on my account, including copays, co-insurance, deductibles, late cancellation fees and non-covered services to my credit card once it is saved in our computer system. If I don’t have a credit card on file, I will be billed for these balances.
By signing below, I am agreeing that I have read, understood, and agree to the items listed above.
Signature*

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