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PATIENT INTAKE FORM
Patient Intake Form
Patient Intake Form
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2025-05-21T02:24:14-04:00
PATIENT INTAKE FORM
Step
1
of
2
50%
First Name
(Required)
Last Name
(Required)
Email
(Required)
Phone Number
Address
(Required)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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State
Date of Birth
MM slash DD slash YYYY
Emergency Contact
Name
Relationship
Telephone
Alt. Phone
Check below the protected health information you (the patient) authorize to be disclosed to your physician or your other healthcare practitioners:
All relevant information regarding your case (e.g. 3D body scan data, physical therapy documentation)
None
Referring or Primary Physician
Do you have a prescription for physical therapy? Prescriptions are required for all patients using insurance. Most insurance companies require a medical necessity for reimbursement.
Yes
No
If yes, please upload your signed prescription for physical therapy.
Max. file size: 128 MB.
Please select the option that applies to you. Please note that we can only bill insurance if you have a medical necessity and a prescription.
(Required)
Self Pay Option: I agree to pay in full at the time of service. I do not want to use any insurance for these services. I fully understand that by selecting this option, I will not come back at a later time requesting superbills for "back-billing" purposes.
Out Of Network Option: I have an insurance policy other than Medicare. Please submit claims to them on my behalf. I will still pay in full at the time of service and will sign and agree to the terms on the OON Check Agreement form.
Medicare: I have Medicare, please bill them for me.
Signature
(Required)
I authorize the release of any medical information necessary to process my claim and payment of benefits.
What concern brings you in today?
What is your diagnosis?
When did your symptoms begin?
Have you had any diagnostic tests performed? List date and body part.
MRI
Nerve conduction study
X-ray
CT scan
Others
Please upload results of any diagnostic tests or imaging you have had.
Max. file size: 128 MB.
Have you had surgery for this or any other condition?
Yes
No
Prior Medical History:
Are you currently taking any medications?
Yes
No
Does anything make your symptoms better?
Does anything make your symptoms worse?
Please indicate if you have any of these concerns:
Pain
Decreased Mobility
Swelling/Edema
Stiffness
Loss of function
If you have pain, is it:
Sharp?
Burning?
Intermittent?
Superficial?
Dull?
Stabbing?
Constant?
Shooting?
Tingling?
Deep?
Others
Area of body
Knee Pain
Back Pain
Hip Pain
Shoulder Pain
Ankle Pain
Foot Pain
Neck Pain
Elbow Pain
Chest Pain
Wrist Pain
Joint Pain
How severe is your pain: 0= no pain, 10= excruciating pain?
1
2
3
4
5
6
7
8
9
10
Have you been treated for this problem before? (e.g. PT, chiropractor, yoga, massage)
Type of treatment
Duration of treatment
Was it effective? If so, how?
Type of treatment
Duration of treatment
Was it effective? If so, how?
Type of treatment
Duration of treatment
Was it effective? If so, how?
How many days a week do you exercise?
0 days/week
1-2 days/week
3 days/week
5 days/week
7 days/week
Current emotional stress scale:
1
2
3
4
5
6
7
8
9
10
Do you have difficulty sleeping?
Yes
No
What are your goals for physical therapy?
Decrease pain
Improve range of motion
Return to daily activities
Begin/return to exercising
Improve posture
Other
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