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Patient Intake Form

Patient Intake Formdeveloper2022-03-28T15:17:07-04:00

PATIENT INTAKE FORM

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Check below the protected health information you (the patient) authorize to be disclosed to your physician or your other healthcare practitioners:
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.
Max. file size: 50 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)
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I authorize the release of any medical information necessary to process my claim and payment of benefits.
Have you had any diagnostic tests performed? List date and body part.
Max. file size: 50 MB.
Have you had surgery for this or any other condition?
Are you currently taking any medications?
Please indicate if you have any of these concerns:
If you have pain, is it:
Area of body
How severe is your pain: 0= no pain, 10= excruciating pain?

Have you been treated for this problem before? (e.g. PT, chiropractor, yoga, massage)

How many days a week do you exercise?
Current emotional stress scale:
Do you have difficulty sleeping?
What are your goals for physical therapy?
Please complete the documents below(Required)
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