Injury Intake Form

What is your reason for the visit?

Name

First NameLast Name

Age

Sex

MaleFemale

Date of Birth

Date

Occupation

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

E-mail

example@example.com

Reason for your visit

History of current or previous injuries

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 better and worse?

How often do you experience the pain/symptoms?

Are your symptoms related to a work injury?

YesNo

Or a motor vehicle accident?

YesNo

Past Medical History (past surgeries, medical illness, etc)*

List of Medication*

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?

What activities is the injury limiting

Additional health information or questions:

I hereby authorize the specific personnel/healthcare individuals to gather all the necessary details needed for my appointment to ensure the safety of both the patient and the provider.I understand that my personal health information is subject to disclosure by the provider.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.

1.) CANCELLATIONS

Cancellations should be made at least 24 hours in advance of a scheduled session. Sessions cancelled less than 24 hours in advance will be charged in full to the client.

2.) LATE ARRIVALS

Each session shall be 1 hour in length. Sessions will not be extended (unless time is available) due to the lateness of the client or due to interruptions caused by the client.

3.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential and have completed the liaility waiver.

4.) Payment

I agree to make the payment of $150 for the first rehab wellness, $130 for follow ups, OR $100/per person in training for each 1 hour session to Austin Shutler via venmo, zelle, wix, or cash as desired per client. Session frequency may vary depending on discussed agreement. I recognize that Awakening wellness is not a physical therapy corporation or entity and will not recieve documentation to use for reimbursement.

Name & signature of patient/legally responsible person

Date Signed

Date

Patient Injury Intake Form

Personal Information

Current Symptoms

History

Authorization/Consent