Dr. Katherine Shephard, PT, DPT : Intake Form

Name

First NameLast Name

Pronouns

Date of Birth

Mobile Number

Please enter a valid phone number. (Required for SMS appointment reminders)

Home Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Occupation

Emergency Contact

Name, Relationship & Phone Number

List any other major medical conditions or injuries you have/had*

List any past surgeries*

How would you describe your general state of health?

ExcellentGoodFairPoor

Medical History

Current emotional stress scale (O- No Stress / 10 - Extremely Stressed)

Do you smoke?

CurrentNeverPast

Do you drink alcohol?

CurrentNeverPast

Do you use recreational drugs?

CurrentNeverPast

Do you have chronic pain?

CurrentNeverPast

Activity Level

What specifically brings you to therapy? When did your symptoms begin?

How is this affecting your life (relationships, getting around, socializing, etc.)?

What makes it worse?

What makes it better?

Are you (or could you be) pregnant? If yes, what is your estimated due date?

How many pregnancies have you had?

Number of vaginal deliveries

Number of cesarean deliveries

What else would you like your physical therapist to know?

Consent for Physical Therapy

I hereby authorize Katherine Shephard and/or such assistants to provide physical therapy services. I acknowledge that the purpose of physical therapy is to diagnose and treat disease, injury and disability by use of rehabilitative procedures, mobilization, massage, exercise, and physical agents to aid in achieving maximum potential, accelerating recovery and reducing the length of functional impairment. I understand that all procedures will be thoroughly explained to me before I am asked to perform them.

I accept the treatment recommendation of my physical therapist. I acknowledge that no warranty or guarantee has been made as to the results of this therapy. I understand that any aspect of this consent form that I do not understand will be explained to me in further detail by asking my physical therapist. It is my right to ask my physical therapist about the treatment plan based on my individual history, physical therapy diagnosis, symptoms, and examination results. I further certify that my physical therapist has informed me of the nature and character of the proposed treatment, of the anticipated result, alternative treatment choices, and the possible risks, complications, and anticipated benefits involved in the proposed therapy.

I consent, by my own free will, to voluntarily engage in an in-person session or Telehealth/virtual session through telephone or video conferencing.

Signature

Please check that all required questions have been answered.

Intake form for Dr Katherine Shephard, PT, DPT

Questionnaires