Physical Therapy Patient Intake Form
First Time Visit?
Yes
No
If No, when was the last visit?
-
Month
-
Day
Year
Date
What is your reason for the visit?
Personal Information
Name
First Name
Last Name
Age
Sex
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
SS#
Marital Status
Single
Married
Divorced
Widowed
Rather not say
Occupation
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer Name
Phone Number
-
Area Code
Phone Number
E-mail
Emergency Contact
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relation
Referring Physician
First Name
Last Name
Physician's Phone Number
-
Area Code
Phone Number
Primary Care Physician Name
First Name
Last Name
Insurance Information
Name of Insurance Company
Policy #
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insured's Name
First Name
Last Name
Insured's SS#
Date of Birth
-
Month
-
Day
Year
Date
Insured’s Employer Name:
Insured's relationship to patient
Current Symptoms
Reason for your visit
Rate your chief complaint in order of severity from worst (5) to least (1)
Please Select
1
2
3
4
5
Indicate the nature of your pain and symptoms
Sharp
Dull
Piercing
Shooting
Aching
Tingling
Numbness
Stabbing
Other
What makes your condition worse?
What makes your condition better?
How often do you experience the pain/symptoms?
Are your symptoms related to a work injury?
Yes
No
Or a motor vehicle accident?
Yes
No
List past surgeries or major medical problems/illness
*
List of Medication
*
Since your symptoms began, have you noticed any of the following
Fatigue
Pain at night
Leg swelling
Weight loss/gain
Numbness or tingling
Abdominal pain
Fainting
Skin changes
Heart palpitations
Other
History
Yes
No
Tobacco Use
Alcohol Use
High Blood Pressure
Neck or Back Problems
Are you pregnant
Do you have osteoporosis
Allergies
Are you currently under a care of any healthcare provider other than who prescribed your Physical Therapist
Yes
No
If yes, what is the reason?
Schedule
Desired time and day of the meeting.
Day
Please Select
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Time
Please Select
8:00 AM - 9:00 AM
9:00 AM - 10:00 AM
10:00 AM - 11:00 AM
11:00 AM - 12:00 PM
1:00 AM - 2:00 PM
2:00 PM - 3:00 PM
3:00 PM - 4:00 PM
4:00 PM - 5:00 PM
Comments
Authorization/Consent
I hereby authorize the specific personnel/healthcare facility to gather all the necessary details needed for my appointment to ensure the safety of both the patient and the therapist. I understand that my personal health information is subject to disclosure by the facility receiving it for legal purposes. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the practice. I authorize my insurance benefits to be charged directly the facility and that I am responsible for any cost in any case my insurance claim be denied.
Name & signature of patient/legally responsible person
Reason why patient is unable to sign
Date Signed
-
Month
-
Day
Year
Date
Submit Form
Should be Empty: