New Patient Intake Form

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

What is your main concern?

(Please tell us body region and a bit about your symptoms)

When did this begin?

How do these concerns affect your quality of life?

(Please tell us if you are limited from doing anything specific)

Have you seen anyone else for this? If yes, who?

Describe any treatment you have received and the results?

What aggravates the condition?

What improves the condition?

What do you believe is causing your most important health concern?

How would you describe your general state of health? (Check one)

Describe any notable events in your past medical history - please list things that you don't believe are related:

Do you have any allergies? If so, what?

Cardiovascular Conditions: Please check the boxes for any conditions you have experienced or are experiencing:

Respiratory Conditions: Please check the boxes for any conditions you have experienced or are experiencing:

Communicative Diseases: Please check the boxes for any conditions you have experienced or are experiencing:

Bone Health: Please describe any history of fractures:

Osteoporosis / Osteopenia

Arthritis

Diabetes

Epilepsy

Cancer

Do you have a family history of any of the above conditions? If yes, please describe:

Head/Neck Conditions: (Please check all that apply)

Other Conditions: (Please check all that apply)

Please list any surgical procedures:

Habits and Lifestyle: (Please check all that apply)

Current Emotional Health: (How stressed are you from 1-10 - 1 being no stress and 10 being extremely stressed?)

1-10

Please list any medications and supplements:

Are you currently pregnant? If yes, please list due date:

Number of prior pregnancies:

Have you experienced changes in your continence? If so, please describe:

Do you have a past history of trauma?

I understand that Barton County Physical Therapy and Wellness will maintain my privacy to the highest standards and may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided, and any administrative operations related to treatment and payment. I give Barton County Physical Therapy and Wellness permission to communicate via text, email, and leave voicemails for necessary communication:

I understand that photographs taken during initial evaluation, progress evaluations, and discharge summary will be used for postural comparison purposes and as an educational tool and give permission for such photographs/videos to be taken:

I give my consent to Barton County Physical Therapy and Wellness to furnish care and treatment that is considered necessary and proper in the diagnosing and/or treatment of my physical condition. I understand that I will always maintain bodily autonomy and have full control over further treatments that will be discussed with my therapist:

Important Financial Information

In order to maintain the highest quality of service as well as to continue progressing with the established plan to help reach your goals we ask that you show us consideration with the following:

Cancellation within 24 hours or a failure to arrive at your scheduled appointment will be billed at the cost of a standard physical therapy visit. Please Call or follow instructions in your appointment confirmation e-mail for all cancellations and appointment rescheduling.
Payment Schedule: I understand that fees for services are due at the end of each session unless written agreement is made with the clinic.
Payment Options: Check/Credit Card/Cash/Online portal.
Insurance Claims/Billing: I understand that the full fee for each session is due and payable at the time of service unless agreed upon with my therapist. I am responsible for filing my own insurance claims. Barton County Physical Therapy and Wellness will provide me a superbill if desired containing the pertinent information to file a claim with my insurance carrier so that I may receive reimbursement if covered under my health plan.
Returned Checks: I agree to pay $40 for checks returned due to non-sufficient funds.
Late Starting Appointments: I understand that if I am late, the session will conclude at the scheduled time to show consideration for other clients scheduled following.

Do you agree to the above statements?

Out of these options, which would you choose FIRST?

New Patient Intake Form

General Health:

Pelvic Health:

Consent to Treat and Communication:

Cancellation Policy:

Just For Fun: