PHYSICAL THERAPY INTAKE FORM
Disclaimer: Thank you for your interest in being a client of .
Information collected about new clients is confidential and will be treated accordingly.
PATIENT INFORMATION
Full Name: _____________________________ Email: ___________________________
Address: ____________________________________________________________________
Phone: _______________ DOB: ______________ Age: _______ Gender: ______________
Preferred Contact Method: ☐ E-mail ☐ Phone ☐ Text Message
Emergency Contact: _____________________ Phone: ______________________
Emergency Contact Relationship: _____________________
Employer: ______________________ Occupation: ______________________
Referred by: _________________________
INSURANCE INFORMATION
Primary Insurance Company: _________________________
Group #: _________________________ ID#: _________________________
Policyholder Name: _________________________ DOB: ______________
Relationship to Patient: _____________________
Secondary Insurance Company: _________________________
Group #: _________________________ ID#: _________________________
Policyholder Name: _________________________ DOB: ______________
Relationship to Patient: _____________________
REFERRING PHYSICIAN
Referring Physician: _________________________ Phone: ______________________
Date of next visit with referring physician: ______________
Primary Care Physician: _________________________ Phone: ______________________
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PATIENT INJURY OR CONDITION
Height: _________ Weight: _________
Type of Injury/Condition: ______________________________________________________
Date of Injury/Onset: ______________
Type of Surgery/Procedure: ____________________________________________________
Date of Surgery: ______________
Please describe your physical limitations as a result of this injury/surgery:
Please describe any activities or movements that aggravate your symptoms:
Please describe any treatments, movements, or self-care that decrease your symptoms:
Please list any previous injury, conditions, or surgeries:
Have you had any of the following diagnostic tests in relation to this injury?
☐ X-Ray ☐ MRI ☐ CT Scan ☐ Doppler ☐ Ultrasound ☐ Other: ___________________
Which of the following describes your pain? (check all that apply)
☐ Sharp ☐ Achy ☐ Burning ☐ Tingling ☐ Numbness ☐ Other: ___________________
Are you currently taking any medications? ☐ Yes ☐ No
Please list all medications and dosages:
Please rate your pain: (0=None, 5=Moderate, 10=Severe)
At present: ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 ☐ 7 ☐ 8 ☐ 9 ☐ 10
At best: ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 ☐ 7 ☐ 8 ☐ 9 ☐ 10
At worst: ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 ☐ 7 ☐ 8 ☐ 9 ☐ 10
Is your injury the result of a fall? ☐ Yes ☐ No
Have you fallen twice or more in the past year? ☐ Yes ☐ No
Dates of falls: ________________________________________________________________
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PATIENT MEDICAL HISTORY
Have you been diagnosed with any of the following conditions? (check all that apply)
☐ Allergies ☐ Diabetes ☐ Metal implants
☐ Anemia ☐ Dizziness/vertigo ☐ Multiple sclerosis
☐ Anxiety ☐ Emphysema/Bronchitis ☐ Neurological disorder
☐ Arthritis ☐ Fibromyalgia/Chronic fatigue ☐ Numbness/tingling
☐ Asthma ☐ Fractures ☐ Osteoporosis/Osteopenia
☐ Bladder/Bowel problems ☐ Gastrointestinal problems ☐ Pain syndrome/CRPS
☐ Cancer ☐ Gallbladder/Kidney problems ☐ Parkinson’s
☐ Cardiac disease/conditions ☐ Headache/Migraines ☐ Seizures
☐ Pacemaker/defibrillator ☐ Hepatitis ☐ Speech problems
☐ Circulation problems ☐ Hernia ☐ Strokes
☐ Currently pregnant ☐ High blood pressure ☐ Thyroid problems
☐ Depression ☐ Incontinence ☐ Vision problems
Please describe in detail any diagnosis checked above:
Have you suffered from any illness not listed here? ☐ Yes ☐ No
If yes, please explain:
TREATMENT HISTORY
Have you been treated for this condition before? ☐ Yes ☐ No
If yes, by whom? __________________________________ Was it helpful? ☐ Yes ☐ No
What are your goals for Physical Therapy?
What do you hope to get out of your treatment?
What are your current physical or fitness goals?
Please list any important dates, such as return to sport/performance/games, coming up
for which you want to be physically ready: _______________________________________
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Is there anything else that you would like to include or ask your therapist?
HEALTH HABITS & LIFESTYLE
Do you eat a well-balanced diet? ☐ Yes ☐ No
Do you drink water regularly? ☐ Yes ☐ No If yes, how many glasses per day? _______
Do you exercise regularly? ☐ Yes ☐ No If yes, how many times per week? _______
Exercise type/program: ____________________________
Do you have any hobbies/leisure activities? ☐ Yes ☐ No Type: __________________
Do you smoke? ☐ Yes ☐ No If yes, how many per day? _________
For how long? ___________________
Do you drink alcohol? ☐ Yes ☐ No If yes, how many per week? _________
CONSENT FOR CARE AND TREATMENT
I, the undersigned, hereby agree and give my consent for the physical therapist named in this
document to furnish physical therapy care and treatment considered necessary and proper in
evaluating or treating my physical condition. _____ (Patient initial)
FOR MINORS ONLY: CONSENT FOR CARE: As parent and/or legal guardian, I
authorize the physical therapist named in this document to treat the minor patient named
in the attached forms while I am not present. _____ (Parent/Guardian initial)
By signing below, I agree that all of the above information is correct, and that I authorize the
physical therapist named in this document to provide me with therapy services and to furnish my
physician, insurance company or attorney information concerning my injury and treatment.
CLIENT SIGNATURE
Signature: ______________________ Date: ______________________
Print Name: ______________________
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