Patient Intake

Full Name

First NameLast Name

E-mail Address

example@example.com

Contact Number

Format: (000) 000-0000.

Address- Please upload a Government issued ID.

Street Address

Street Address Line 2

CityCounty

Post Code

Date of Birth

DayMonthYear

File Upload

Photo of the government issued ID (front and back)

Insurance information

Insurance NameMember ID Information

File Upload

Photo of the health insurance card (front and back)

What is the primary reason for your physical therapy visit? *

Do you have a physical therapy referral? If yes, please enter the full name on the line below of the referring licensed health care professional ( MD, DO, Physician Assistant, NP, Dentist, other health care practitioner licensed by The State of New York )Type a label Also, please upload a copy of the physical therapy referral below.

File Upload

Please upload the copy of the physical therapy referral.

Is this a pediatric case?

Does your child has an IEP? If yes, unfortunately we are not be able to see school age patients with IEP in the school.

Is this a No Fault Case? If the answer is yes, please upload the insurance information (e.g adjuster’s name and contact information)

File Upload

For No-Fault Case- please upload the documents: Police Report, Adjuster information, Lawyer information)

Is this a worker’s compensation case? Please note that we need the C-4 Authorization before we can see you for physical therapy or call us if you have questions.

File Upload

Approved C-4 Authorization

Has your doctor ever said your blood pressure was too high or too low?

Do you have a pacemaker or defibrillator ?

Other

Please provide details.

Do you have any known cardiovascular problems (abnormal EKG, previous heart attack, etc)?

Please provide details.

Has your doctor ever told you that your cholesterol was too high?

Please provide details.

Have you (or a family member) ever been told that you have diabetes?

Please provide details.

Do you have any injuries or orthopedic problems (back, knees, etc)?

Please provide details.

Do you have stiff or swollen joints?

Please provide details.

Do you have tension or soreness in any area?

Please provide details.

Are you taking any prescribed medications or dietary supplementation?

Please provide details.

Do you ever have problems sleeping?

Are you pregnant or post-partum (< 6 weeks)?

Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise/activity?

Please provide details.

Do you have osteoporosis?

Do you have any other medical condition, injury or anything else we should be aware of that we have not mentioned? e.g. food allergies, allergies to LATEX, seasonal allergies.

Do you have any lung problems? Please specify below.

Please provide details.

Signature

My signature attest that the information provided is true to the best of my knowledge. I also consent to submit my personal information for physical therapy evaluation and treatment at KinesioWorks Physical Therapy.

Appointment