Physical Therapy Intake Form

Physical Therapy Patient Intake Form
First Time Visit?
If No, when was the last visit?
MonthDayYear
Date
What is your reason for the visit?
Personal Information
Name
First NameLast Name
Age
Sex
Date of Birth
MonthDayYear
Date
Marital Status
Occupation
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Employer Name
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Emergency Contact
Name
First NameLast Name
Phone Number
Format: (000) 000-0000.
Relation
Referring Physician
First NameLast Name
Physician's Phone Number
Format: (000) 000-0000.
Primary Care Physician Name
First NameLast Name
Insurance Information
Name of Insurance Company
Policy #
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Insured's Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Insured’s Employer Name:
Insured's relationship to patient
Current Symptoms
Reason for your visit
Rate your chief complaint in order of severity from worst (5) to least (1)
Indicate the nature of your pain and symptoms
Other
What makes your condition worse?
What makes your condition better?
How often do you experience the pain/symptoms?
Are your symptoms related to a work injury?
Or a motor vehicle accident?
List past surgeries or major medical problems/illness
List of Medication
Since your symptoms began, have you noticed any of the following
Other
History
1
Rows Yes No
Tobacco Use
Alcohol Use
High Blood Pressure
Neck or Back Problems
Are you pregnant
Do you have osteoporosis
Allergies
Are you currently under a care of any healthcare provider other than who prescribed your Physical Therapist
If yes, what is the reason?
Schedule
Desired time and day of the meeting.
Day
Time
Comments
Authorization/Consent
- I hereby authorize the specific personnel/healthcare facility to gather all the necessary details needed for my appointment to ensure the safety of both the patient and the therapist.
- I understand that my personal health information is subject to disclosure by the facility receiving it for legal purposes.
- I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the practice.
- I authorize my insurance benefits to be charged directly the facility and that I am responsible for any cost in any case my insurance claim be denied.
Name & signature of patient/legally responsible person
Clear
Reason why patient is unable to sign
Date Signed
MonthDayYear
Date
Should be Empty:

Select theme:

Rows	Yes	No
Tobacco Use
Alcohol Use
High Blood Pressure
Neck or Back Problems
Are you pregnant
Do you have osteoporosis
Allergies

Physical Therapy Patient Intake Form

Personal Information

Emergency Contact

Insurance Information

Current Symptoms

History

Schedule

Authorization/Consent