Physical Therapy Client Intake

Name

First NameLast Name

Preferred Name

What would you like us to call you

Date of Birth

Date

If Under 18, Guardian Name

If Under 18, Guardian Date of Birth

If Under 18, Guardian Contact Number

Email

example@example.com

Mailing Address

Street Address or PO Box

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Primary Insurance Carrier

Insurance ID #

Secondary Insurance Carrier

Insurance ID #

Occupation and Employer

Gender

If Female, Are you Pregnant

Height

Weight

Handedness

Primary Care Physician/Clinic

Referring Doctor

Reason for Physical Therapy

For Example: Back Pain, Muscle Weakness, etc.

Date of Onset

Date of Surgery (If applicable)

Special Tests Done

For Example: X-Rays, MRI, etc.

Check which apply:

What treatments have you tried?

List Medications you are taking

Allergies

Sensitivity or Allergy to Latex

History of:

Current:

Please describe the specific issue you are coming in for and any body parts that are affected.

Draw on the image to indicate where your pain is:

Check all that apply to categorize your pain:

Rate your pain right now

0 if non-existent, 10 unbearable

Rate your pain when it is at its best

0 if non-existent, 10 unbearable

Rate your pain when it is at its worst

0 if non-existent, 10 unbearable

What makes your pain better

What makes your pain worse

Do you smoke?

Do you drink alcohol?

Do you regularly exercise?

Are you feeling down, depressed, or hopeless?

Do you live alone?

Do you have stairs at home?

What is your goal for therapy at this time?

For example: relieve pain, return to previous level of function, gain strength

Are there any important activities you are unable to do due to your pain/symptoms?

For example: Walking up stairs, reaching overhead, rising from a seated position

If you are able to do so, please upload a picture of your ID, insurance card, and any other documents (such as MRI results, referral, etc.) we may need.

If there is anyone you authorize to pick up your private health documents on your behalf, please list their name below.

I, the undersigned, do hereby agree and give my consent for Custom Fitness, LLC to furnish medical care and treatment t that is considered necessary and proper in diagnosis or treatment.

I authorize Custom Fitness, LLC to release to the insurance carrier any information needed for the payment of any claim. I authorize payment to Custom Fitness, LLC from my insurance carrier or third party payer. I agree to pay any applicable cash payments, co-payments, coinsurance and/or deductibles at the time of service and as agreed between Custom Fitness, LLC and me. I understand that my insurance benefits may not cover all charges and that I am responsible for those charges not covered by my health insurance or third party payer. I understand and agree that if I fail to make any of the payments for which I am responsible in a timely manner, I will be responsible for all costs of collecting monies owed, including court costs, collection agency fees, and attorney fees. The above may not apply for those patients that are considered Worker’s Compensation. However, be advised if you claim Worker’s Compensation benefits and are subsequently denied such benefits, you may be held responsible for the total amount of charges for services rendered to you. By my signature, I authorize Custom Fitness, LLC, to release all information necessary, including medical records, to secure payment.

To receive the most benefit from rehabilitation, it is important that you follow the treatment plan prescribed by your physician and therapist and attend all sessions on a regular basis. We ask that you give us at least prior day notice if you must cancel your appointment. Cancellations made on the same day and/or NO-SHOW appointments may be subject to a charge which will be billed directly to you. Insurance companies will not cover missed appointment charges. If you miss 2 consecutive appointments without notice, all subsequent appointments will be canceled and your failure to comply with your treatment plan may be reported to your primary care physician and insurance company.

I have had full opportunity to read the Custom Fitness, LLC Notice of Privacy Practices. I understand that by signing this consent, I am giving my consent to Custom Fitness, LLC to use and disclose my protected health information to carry out treatment, payment activities and health care operations. I understand the terms of this notice may change with time

I authorize Custom Fitness to contact me as necessary.