Injury Screen Intake Form

Injury Screen Intake Form

HIPAA-compliant patient intake for injury screening for Physical Therapy San Pedro. Please complete all applicable sections.
Patient Information
Today's Date

MonthDayYear
Date
Patient Last Name
Patient First Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
ZIP
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Age
Marital Status
Email
example@example.com
Occupation
Employer
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Physicians and Referral Source
Primary Care Physician Name

First NameLast Name
Primary Care Physician - Date of Next Visit

MonthDayYear
Date
Specialist Physician Name

First NameLast Name
Specialist Physician - Date of Next Visit

MonthDayYear
Date
How did you hear about our practice?
Who can we thank for referring you to our practice?
Current Condition and Pain
Primary issue/problem that brings you in today
Secondary concern/problem
Resulting difficulties
Current pain description
Symptom onset date

MonthDayYear
Date
Pain rating - At its worst

0

1

2

3

4

5

6

7

8

9

10

0 is No pain, 10 is Worst pain
Pain rating - At its best

0

1

2

3

4

5

6

7

8

9

10

0 is No pain, 10 is Worst pain
Pain rating - At present

0

1

2

3

4

5

6

7

8

9

10

0 is No pain, 10 is Worst pain
Pain rating - Night

0

1

2

3

4

5

6

7

8

9

10

0 is No pain, 10 is Worst pain
Pain location diagram notes
Time of day symptoms are worst
Time of day symptoms are best
Activities that increase pain
Activities that decrease pain
Prior Treatment and Medical History
Prior Treatments

Other
Other Medical Treatment
Medical Conditions

Other
Other Medical Conditions
Past Medical History
Medications
Medication 1 - Name
Medication 1 - For treatment of
Medication 1 - Dose / Amount per day
Medication 1 - Effectiveness
Medication 2 - Name
Medication 2 - For treatment of
Medication 2 - Dose / Amount per day
Medication 2 - Effectiveness
Medication 3 - Name
Medication 3 - For treatment of
Medication 3 - Dose / Amount per day
Medication 3 - Effectiveness
Health Habits and Exercise
Do you smoke?
If you smoke, how much?
When did you quit smoking?
If not smoking, would you like to quit?
Is there a chance you may be pregnant at this time?
Do you engage in regular exercise?
Exercise type and frequency
Are you able to exercise now?
Do you have discomfort, shortness of breath, or pain with exercise?
Exercise-related symptoms description
Lifestyle activity level
Sleep, Function, and Goals
Do you have trouble falling asleep?
Is your sleep restful?
Do you find it difficult to lie down?
Do you find it difficult to change positions in bed?
How many times do you wake in the night?
How long before you fall back to sleep?
Tasks/Activities with difficulty
Patient Goals
Other Goals
Sleep-related questions and goals should be completed if sleep is a problem.
Please describe any activities that are difficult due to pain, stiffness, or sleep disruption.
List up to three tasks or activities that are most limited.
Include realistic goals for function, sleep, and daily activity.
If applicable, note any strategies that help you return to sleep.
If you have no current sleep concerns, you may leave the sleep questions blank.
Document your preferred timeline for each goal when possible.
Should be Empty:

Injury Screen Intake Form

Patient Information

Physicians and Referral Source

Current Condition and Pain

Prior Treatment and Medical History

Medications

Health Habits and Exercise

Sleep, Function, and Goals