Abilities Rehabilitation & Wellness, PLLC Client Intake Form

CLIENT INTAKE FORM
Full Name*

First NameLast Name
Phone Number*
(xxx) xxx-xxxx
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
What is your Gender?*

MaleFemaleOther
Date of Birth*

MonthDayYear
HEALTH INSURANCE (Only enter this if you would like for us to bill your insurance for your care and you are not utilizing self-pay.)
Member ID:
Primary Care Physician (PCP)
Last visit with PCP
Referring Provider (If not PCP)
REASON FOR SEEKING PHYSICAL THERAPY?*
MEDICAL HISTORY*

NONEAnemiaArthritisAsthmaBleeding DisordersCardiac (Heart) DiseaseCommunicable Disease (HIV, HPV, MRSA, etc.)COPDDepressionDiabetes (I or II)DizzinessEpilepsy (Seizures)GoutHeadachesHigh CholesterolHypertensionIrregular or Rapid HeartbeatJoint Replacement/Metal ImplantKidney ProblemsMultiple SclerosisMotor Vehicle InjuryOsteoporosisPacemaker/DefibrillatorPsychiatric Disorder(s)StrokeWork InjuryOther
ARE YOU EXPERIENCING ANY OF THE FOLLOWING?*

NONEProductive CoughCoughing BloodFever/ChillNight SweatsNausea/VomitingChest PainTrouble BreathingJoint PainJoint StiffnessRash or Skin ChangesVisual ChangesHearing ChangesConstipationBlood StoolsDiarrheaDifficulty or Pain with UrinationIncontinent BladderIncontinent BowelOther
SURGICAL HISTORY (if applicable)
CURRENT MEDICATIONS
Write NONE if you are currently not on any medications.
DO YOU HAVE ANY ALLERGIES?
Write NONE if you do not have any allergies.
Do you use or do you have history of using tobacco?*
How often do you consume alcohol?*

DailyWeeklyMonthlyOccasionallyNever
Do you exercise?
EMERGENCY CONTACT*
Name & Phone Number
Upload any important medical documents/referrals you would like to share with us.

Browse Files

Cancelof
What date is your first availability for an appointment?

MonthDayYear
This is a Health Insurance Portability and Accountability Act (HIPAA) Complaint Form. All of your information will remain confidential between you and Abilities Rehabilitation & Wellness, PLLC
Should be Empty:

CLIENT INTAKE FORM