Upright Athlete Physical Therapy Intake Form
Name
*
First Name
Last Name
Preferred Name/ Pronouns
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth- PATIENT
*
-
Month
-
Day
Year
Date
Gender
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
What Location are you being seen at?
Durham (4221 Garrett Road Ste 1-2, Durham NC 27707)
Hillsborough (101 Meadowlands Dr, Hillsborough, NC 27278)
What Physical Therapist are you scheduled to see?
*
Brian Diaz PT, DPT, CSCS
Gabe Dimock PT, DPT, SFMA Level 1
Patricia Callison PT, DPT
Cole Burton PT, DPT
Unknown
Employment Status
Employed
Full-Time Student
Part-Time Student
Retired
Occupation
*
Employer
Primary Insurance Company (BCBS, Aetna, selfpay..)
*
Subscriber's Name (IF DIFFERENT)
*
First Name
Last Name
Subscriber Date of Birth (IF DIFFERENT)
-
Month
-
Day
Year
Date
Patient's Relationship to Subscriber
*
Self
Spouse
Child
Other
Patient ID # (subscriber #)
*
Group ID #
*
Please upload the FRONT of your driver's license or other identification card below.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload the Front of your insurance card below. (or send to admin@uprightathlete.com for free verification)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload the BACK of your insurance card below.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Current Problem/ Diagnosis:
*
Location of Pain
*
Neck Pain
Back or Hip Pain
Shoulder, Elbow or Hand Pain
Knee, Ankle or Foot Pain
NDI- Please mark the one statement that most closely describes your current condition
ODI- Please mark the one statement that most closely describes your current condition
Quick Dash- Please mark the one number that most closely describes your current condition
LEFS- Please mark the one number that most closely describes your current condition
Activities that make the pain worse
*
Activities that relieve the pain
*
Onset of symptoms
*
Is this related to a...
Work injury
Auto Injury
Sports injury
Other
Describe
Significant Past Medical History (with dates)
Allergies
Current Medications
Is this post surgical?
Yes
No
Date of Surgery
-
Month
-
Day
Year
Date
Are you suffering from any Medical Conditions? Have you had any operations in the past? If so, please explain briefly...
How did you hear about us? Select all that apply
*
Upright Athlete Website
ActivEdge Website
Event
Friend
Other
Please describe
Referring Physician
First Name
Last Name
Physician Phone/ Fax
Please enter a valid phone number.
Signature- Consent to Treat
Date
*
-
Month
-
Day
Year
Date
Signature for Cancellation/ Financial Policy
*
Date
*
-
Month
-
Day
Year
Date
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: