Patient Intake Form

Patient Intake Form

e_physiotherapy
Name

First NameLast Name
Gender

Other
Age
Birth Date

MonthDayYear
Date
Occupation
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you currently married?
Are you currently pregnant / Nursing?
How many children do you have?
What problems are you seeking help for?
Do you have any prescription from a physician or provider for physical therapy? If yes, who is the referring physician?
Check all symptoms that apply

Other
Mark the area of pain below:
Draw on Image
Rate your Pain on a scale from 1 to 10
Indicate the type of pain you're facing

Other
How often do you experience this pain?
Current duration of pain?
Which activity increases your pain?
Which activity decreases / relieves your pain?
Does "resting" decrease your pain?
Does your pain radiate anywhere in your body? If so, please specify the area/region.
Are your symptoms affected by change in position/ posture? If yes, please specify.
Is your condition related to ________

Other
Are your symptoms related to an injury? If so , please describe what happened
Are your symptoms related to a disease/ medical illness ? If yes , please specify
Please select the option that applies regarding your smoking habits
Average # alcoholic drinks per week?
Average hour of sleep per week?
Do you exercise?
Average # of workouts per week?
List any chronic health problems you may have
List out all current medication
List out allergies
Have you received any treatment for this condition ?
Is there anything else that you would like us to know?
What time works best for you?
Appointment
Date

MonthDayYear
Date
Should be Empty:

Patient Intake Form

Mark the area of pain below: