FWDfuel Physical Therapy Intake Form

First Time Visit?

YesNo

If No, when was the last visit?

Date

What is your reason for the visit?

Name

First NameLast Name

Phone Number

Area CodePhone Number

E-mail

Age

Sex

MaleFemale

Date of Birth

Date

Occupation

Employer Name

Do you regularly sit for your work, use a laptop, or use a sit-stand desk?*

Name

First NameLast Name

Phone Number

Area CodePhone Number

Relation

Referring Physician

First NameLast Name

Physician's Phone Number

Area CodePhone Number

Primary Care Physician Name

First NameLast Name

If direct access/ without referral, would you like us to contact your primary care physician concerning your PT evaluation?

YesNo

Reason for your visit

Rate your chief complaint in order of severity from worst (5) to least (1)

Indicate the nature of your pain and symptoms

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?

YesNo

Or a motor vehicle accident?

YesNo

List past surgeries or major medical problems/illness*

List of Medication*

Have you had your A1C measured in the last year and if so do you know what the number was?*

Do you follow a specific diet or do you react negatively to certain foods?*

To the best of your knowledge, have you ever had exposure to mold or a tick bite?*

Since your symptoms began, have you noticed any of the following

	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

YesNo

If yes, what is the reason?

Day

Time

Comments

A physical therapy examination will be performed which may include spinal and physical examination,
orthopedic testing, photographs, specialized instrumentation, and a treatment plan will be documented. There
are several different methods or techniques by which the Provider may deliver treatment, but treatment is
typically delivered by hand. Some treatments may require the use of an instrument or other specialized
equipment. In addition, dry needling, fascial subcutaneous needling (“FSN”), or microneedling may be included
in the treatment protocol. Physical Therapy treatment may reduce pain, increase mobility, and improve quality
of life.

Dry Needling is a skilled technique performed by the Provider using a single-use, single-insertion, sterile
filiform needle, which is used to penetrate the skin or underlying tissue to effect change in body conditions,
pain, movement, impairment, and disability.
Fascial subcutaneous needling (FSN) is a needling therapy that also uses a sterile filiform needle to treat
myofascial pain and muscle dysfunction. FSN involves mechanical stimulation of subcutaneous connective
tissue that has been shown to induce cytoskeletal remodeling and better alignment of collagen fibers.
Microneedling is a technique that uses a handheld, drum- or pen-shaped device with tiny needles that make
precise, microscopic punctures in the skin. The procedure causes “micro-injuries” that do not leave scars and
works to help stimulate the skin to repair itself naturally through a process called dermal remodeling. This
process causes temporary inflammation, which stimulates the skin to produce new collagen. Collagen levels in
the skin decline with age and new collagen can be produced as a result of the procedure. A minimum of three
(3) to five (5) monthly treatments are recommended to achieve results. Initial results may be expected two (2) to
four (4) weeks after the third session.

RISKS AND COMPLICATIONS
No treatment of procedure is completely risk-free. The following risks may occur, but there may be unforeseen
risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate a higher
level of care and further treatment.
It has been explained to me that there are certain inherent and potential risks and side effects in treatment and in
this specific instance such risks include but are not limited to:
Post treatment discomfort, swelling, redness, and bruising,
Muscle spasms,
Infection,
Aggravating and/or temporary increase in symptoms,
Lack of improvement of symptoms,
Accidental puncture of a lung (dry needling),
Skin damage, bleeding, itching, peeling (microneedling)
Fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains.
I understand that there may be a higher possibility of side effects if I do not follow post treatment instructions. I
will adhere to these instructions. Additionally, I do not expect the Provider to be able to anticipate and explain
all risks and complications, and I wish to rely on her to exercise judgment during the course of the treatment,
based on the facts then known is in my best interest.

Dry needling (DN) is a skilled technique performed by a physical therapist using a single-use, single-insertion, sterile filiform needle, which is used to penetrate the skin or underlying tissue to effect change in body conditions, pain, movement, impairment, and disability. Like any treatment, there are possible complications. While these complications are rare in occurrence, they are real and must be considered prior to giving your consent for dry needling treatment.

Fascial subcutaneous needling (FSN) is a needling therapy that also uses a sterile filiform needle to treat myofascial pain and muscle dysfunction. FSN involves mechanical stimulation of subcutaneous connective tissue that has been shown to induce cytoskeletal remodeling and better alignment of collagen fibers by means of mechanotransduction (Langevin, et al., 2006). The mechanical forces incited within the soft tissue are crucial to the homeostasis of cell and tissue morphology and function as well as influencing the cytoskeletal organization and gene expression (ie. collagen), eventually eliciting a profound effect on the activity of the cell’s nucleus.

There are other conditions that require consideration, so please answer the following questions:

Are you taking blood thinners?

YesNo option 2

Are you or is there a chance you could be pregnant?

YesNo option 2

Are you aware of any problems or have any concerns with your immune system?

YesNo option 2

Do you have any known disease or infection that can be transmitted through bodily fluids?

YesNo option 2

I have read and fully understand this consent form and attest that no guarantees have been made on the success of this procedure related to my condition. I am aware that multiple treatment sessions may be required, thus this consent will cover this treatment as well as subsequent treatments by this facility. All of my questions, related tothe procedure and possible risks, were answered to my satisfaction.

I consent:

YesNo option 2

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 Omnia Function LLC 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.

Name & signature of patient/legally responsible person

Reason why patient is unable to sign

Date Signed

Date

Physical Therapy Patient Intake Form

Personal Information

Emergency Contact

Current Symptoms

History

Schedule

Dry Needling & Fascial Needling Consent

Authorization/Consent