Peak Rehabilitation Client Intake Form

Physical Therapy Intake Form

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent.
New Patient Information
Today's Date*

MonthDayYear
Date
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date*

MonthDayYear
Phone Number*
Format: (000) 000-0000.
E-mail
example@example.com
Social Security Number*
Sex:
Status:*
Date Of Injury or Onset Date
Auto Accident?*

YesNo
Work Related?*

YesNo
Primary Insurance
Name of Insurance Company*
Member ID:*
Group #:*
Policy Holder Name:*
Policy Holder Date of Birth*

MonthDayYear
Date
Policy Holder SS#*
Policy Holder Employer
Policy Holder Contact Phone Number
Patient Relationship to Policy Holder?*
Guarantor Information For Minor Patient

Parent Who Brings The Patient For Treatment
Parent Name:
Parent SS#:
Parent Date of Birth

MonthDayYear
Date
Name of Employer:
Employer Phone:
Patient Employer Information
Employer Name:
Employer Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Employment Status:*
Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information
Emergency Contact Name*
Best Emergency Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Can We Speak With This Person*

YesNo
Relationship To Emergency Contact?*
Physician Information
Name of Referring Physician:
Referring Physician Phone #?
Please enter a valid phone number.Format: (000) 000-0000.
Name of Primary Care Physician:
Primary Care Physician Phone #?
Please enter a valid phone number.Format: (000) 000-0000.
Past Medical History
List Areas of Discomfort, Pain or Current Symptoms
Describe Onset of Discomfort or Pain
Rate of Pain Today
Have you ever injured this area before?
Check how the injury occurred:*

Work Related InjuryMotor Vehicle AccidentRecurrence of Previous InjuryInjury Related To LiftingInjury Related To FallAthletic or Recreational InjuryUnknown Cause Of Injury
Do you have, or have had any of the following conditions?

DiabetesChest Pain/AnginaHeart DiseaseHeart AttackHeart PalpitationsPacemakerHeadachesKidney ProblemsCancerOsteoporosisBowel/Bladder AbnormalitiesUrine LeakageAsthma/Breathing DifficultiesLiver/Gallbladder ProblemsSmokingAllergy To AspirinAllergy To HeatAllergy/Poor Tolerance ColdHerniaSeizuresMetal ImplantsDizziness/FaintingRecent FracturesSurgeriesSkin AbnormalitiesSexual DysfunctionNausea/VomitingRinging in earsRheumatoid ArthritisSpecial Diet GuidelinesStroke/CVA
If you selected any of the above, please briefly explain and give approximate dates:
Are You Pregnant?*

YesNo
Are You Taking Any Medications?*

YesNo
Please list names of medications and dosage:
Mark Where You Are Experiencing Issues.
Patient Signature*

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Parent Signature if patient is a minor

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Date*

MonthDayYear
Date
Should be Empty:

Physical Therapy Intake Form

New Patient Information

Primary Insurance

Guarantor Information For Minor Patient

Patient Employer Information

Emergency Contact Information

Physician Information

Past Medical History