Intake Form
Name
*
First Name
Last Name
Address
*
Billing Street Address
Street Address Line 2
City
State
Postal / Zip Code
Date Of Birth
-
Month
-
Day
Year
Email
example@example.com
Cell Phone
*
-
Area Code
Phone Number
Home Phone
-
Area Code
Phone Number
Social Security Number:
Appointment Reminders (check all that apply):
Phone Call
Text
Email
How Did You Hear About Us?
Family, Friend, Coworker
Radio Ad
Signage
Newspaper
Doctor (provider or staff specifically said to come to Health In Motion)
Athletic Trainer
I was a prior patient
Event
Other
Occupation
Employer
Employer Phone
Name of Primary Care Provider? (MD,DO,PA,NP)
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Emergency Contact
Please provide us with emergency contact information.
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship
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Insurance Information
Person listed as primary on insurance (Subscriber)
First Name
Last Name
Primary's Date Of Birth
-
Month
-
Day
Year
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Current Symptoms
Please describe your current problems and symptoms.
Problem(s) you are here for?
*
What Date (roughly) did your symptoms start?
-
Month
-
Day
Year
What Do You Think Started Your Symptoms?
Treatments So Far For This Problem (injections, chiropractic, etc.)
Have You Ever Had This Before?
Yes
No
If Yes, What Worked Best For Treatment?
What is YOUR opinion about what is going on?
Have You Had Imaging For This Problem?
Yes
No
If Yes, Please List:
If Yes, what provider group (Aspirus, Bone & Joint, etc.)?
What Makes Your Symptoms Worse?
What Makes Your Symptoms Better?
How long for symptoms to ease after being aggravated?
Are Your Current Symptoms Disrupting Your Normal Sleep Pattern?
Yes
No
Are Your Symptoms Related to a Work Injury?
Yes
No
Are Your Symptoms Related to an Auto Accident?
Yes
No
Is there a pending lawsuit related to this injury?
Yes
No
Do you have benefits through the Black Lung Program?
Yes
No
How Has This Problem Impacted Your Life?
If therapy is successful, how will that progress be measured?
What Are Your Goals for Therapy (beyond pain relief if that is a problem)?
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Medical History
Have You EVER Been Diagnosed With Any Of The Following Conditions? (Check All That Apply)
Cancer
Heart Problems
Chest Pain/Angina
High Blood Pressure
Circulation Problems
Blood Clots
Stroke
Anemia
Chemical Dependency (i.e. alcoholism)
Depression
Anxiety
Lung Problems
Tuberculosis
Sexually Transmitted Disease/HIV
Rheumatoid Arthritis
Osteoarthritis
Bladder/Urinary Tract Infection
Kidney Problem/Infection
Cholesterol - high/low
Thyroid Problems
Diabetes
Osteoporosis
Multiple Sclerosis
Epilepsy
Hepatitis
Ulcers
Liver Problems
Other
If You Selected Cancer Above, Please List The Type and Year(s) You Had Cancer:
SINCE YOUR SYMPTOMS BEGAN, Have You Noted Any Of The Following? (Check all that apply)
Fatigue
Generalized Muscle Weakness
Dizziness/Lightheadedness
Weight Loss/Gain
Difficulty Maintaining Balance While Walking
Changes In Bowel Or Bladder Function
Numbness Or Tingling
Falls
Shortness Of Breath
Heartburn/Indigestion
Difficulty Swallowing
Headaches
Fever/Chills/Sweats
Nausea/Vomiting
Abdominal Pain
Fainting
Coughing
Other
Past Surgical History (Procedure & Date):
Please List Current Medications:
During The Past Year Have You Been Feeling Down, Depressed, Or Hopeless?
Yes
No
During The Past Month Have You Been Bothered By Having Little Interest Or Pleasure In Doing Things?
Yes
No
Are the Previous 2 Items Something With Which You Would Like Help?
Yes
Yes, but not today
No
Do You Ever Feel Unsafe At Home Or Has Anyone Tried To Hit You Or Injure You In Any Way?
Yes
No
If You Are Over 65, How Many Falls Have You Had In The Last 12 Months?
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Authorization
I authorize my insurer to pay any benefits for physical therapy services to Health In Motion (HIM). I understand that anything not covered by my insurance is fully my responsibility. I hereby authorize HIM through its appropriate personnel to perform or have performed on me, or the patient named below, appropriate assessment and treatment procedures relating to my diagnosis. I have reviewed and understand the notice of privacy practices. A copy of privacy practices will be provided upon request.
Patient's (parent/guardian if minor) Electronic Signature
*
Guardian Relationship
Date
-
Month
-
Day
Year
Health In Motion Location You Visit
*
Rhinelander Location
Tomahawk Location
Eagle River Location
Wausau Location
Marshfield Location
Crandon Location
Antigo Location
Merrill Location
New Castle Location
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