Return to Play Intake Form

Ethos Return to Play

Pre-Screen/Intake Form
Please fill out the form below prior to your appointment. The Return to Play Intake Form helps the Ethos team understand your injury history, current condition, and goals as you transition back into training or sport. This information allows our physical therapy and human performance staff to evaluate your readiness, identify any limitations, and create a safe plan to guide your return to activity. Our goal is to support a smooth transition from recovery to performance.
Date

MonthDayYear
Date
Full Name*

First NameLast Name
Parent/Guardian Name if client is a minor

First NameLast Name
Email*
example@example.com
Cell Phone Number*
Format: (000) 000-0000.
Birthdate *
MaleFemaleOther
Date of Injury/ Diagnosis:*

MonthDayYear
Date
Describe injury/diagnosis:*
(aching, cramping, dull, sore, deep, sharp, shooting, stabbing, stinging, tingling, burning, numbness, radiating - if so, where?)
Which body part is affected?
Elbow, shoulder, knee, lower back, etc.
RightLeftBoth
YesNo
Type of Surgery:
Date of Surgery
Treating Physician:
What are the biggest concerns you have with your condition/injury currently? *
Sudden or gradual onset? Mechanism of injury?
What are your main goals, both long term and short term*
Sudden or gradual onset? Mechanism of injury?
Have you received other forms of therapy prior to now? Are you currently engaged in said therapy?*
How have your other therapy experiences been?
NoOther
If so, on a scale of 0-10 (10 being the worst), what would you rate your pain at?*
YesNo
SwellingStiffnessInstability
YesNoSometimes
YesNo
What sports do you play and want to get back to? *
How did you hear about Ethos? *
Any additional questions, comments, or concerns?
Should be Empty:

Ethos Return to Play