TSU TIGER COMMUNITY REHAB CLINIC
Intake Forms
Patient Contact Information
Patient Name:
*
First Name
Last Name
Patient Preferred Name:
Patient Date of Birth:
*
/
Month
/
Day
Year
(mm/dd/yyyy)
Patient Address:
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Patient Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Can You Receive Texts at This Number?
Yes
No
Patient Email:
*
example@example.com
Preferred Method of Appointment Reminders:
*
Email
Text Message
Please Fill Out Parent/Guardian Contact Information If Above Patient is Under 18 Years of Age
Parent/Guardian Name
First Name
Last Name
Parent/guardian Date of Birth
/
Month
/
Day
Year
Date
Relationship to Above Patient
Phone Number
(If Different from Above)
Format: (000) 000-0000.
Email
(If Different from Above)
In case of an emergency, whom should we contact?
Name of Contact:
First and Last
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship:
Back
Next
Patient Prior Medical History
Primary Reason for Visit:
*
Date of injury/onset:
-
Month
-
Day
Year
Date
Please indicate below with a circle where your symptoms are located
*
If you are having pain, please rate the intensity of your pain on a scale of 0-10, 0 being no pain and 10 being the worst pain possible:
Please describe your pain: (stabbing, tingling, numbness, pins and needles, aching, burning, sharp, dull, throbbing, radiating, etc.)
Have you ever had physical therapies (PT or OT) for these symptoms before?
Yes
No
If YES, please describe below what treatment has been provided and if it was helpful:
Please check which apply to your symptoms in reference to the cause:
Work Related Injury
Motor Vehicle Accident
Cause Unknown
Recurrence of Previous Injury
Injury Related to Lifting
Athletic/Recreational Injury
Injury Related to Falling
Other
Have you had a related surgery?
Yes
No
If YES, what was the surgery?
Are you currently seeing a physician?
Yes
No
Date of last physician's visit:
/
Month
/
Day
Year
Date
Are you presently taking medication?
Yes
No
If YES, please list what medications and for what condition:
Are you currently pregnant?
Yes
No
Date of last menstrual cycle (if applicable):
/
Month
/
Day
Year
Date
Are you currently working?
Yes
No
Do you participate in any sports, exercise programs or activities on a regular basis?
Yes
No
If YES, please describe:
Do you have, or have you had, any of the following (please mark the option to indicate "YES"):
Diabetes
Alleries to Aspirin
High Blood Pressure
Allergies/Poor Tolerance to Heat
Hypoglycemia
Allergies/Poor Tolerance to Cold
Heart Disease
Other Allergies
Heart Attack
Special Diet Guidelines
Heart Palpitations
Stroke/CVA
Chest/Angina
Seizures
Pacemaker
Nausea/Vomiting
Surgeries
Dizziness/Fainting
Recent Fracture
Headaches
Metal Implants
Cancer
Skin Abnormalities
Rheumatoid Arthritis
Sexual Dysfunction
Asthma/Breathing Difficulties
Urine Leakage
Ringing in Your Ears
Kidney Problems
Liver/Gallbladder Problems
Hernia
Bowel/Bladder Abnormalities
Smoking
Other
If YES to any of the above, please briefly explain and give an approximate date:
Is there any other information regarding your past medical history that we should know about?
If YES, please explain.
Patient's Signature:
*
Today's Date:
*
/
Month
/
Day
Year
Date
Signature of Parent/Guardian if patient is a minor:
Today's Date:
/
Month
/
Day
Year
Date
Submit
Should be Empty: