Physiotherapy Intake Form
Patient’s Name
First Name
Last Name
Gender
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation/Job Title
Weight (kg)
Height (in)
Do you have your own insurance?
Yes
No
Not applicable
Insurance Company Name
Health Insurance/Medicare Number
Coverage Period
Expiry Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Coverage
Do you have an active lifestyle?
Yes
No
Not applicable
If yes, please provide us with the lists of your physical activities like sports, hobbies, martial arts, and other recreational activities that require being physically active.
Why are you seeking for physiotherapy from us?
Primary physical complaint:
Secondary Complaint
Are you in physical pain right now?
Yes
No
Not applicable
Can you rate the pain from 1-10 with 10 being the highest and most painful?
Less Painful
1
2
3
4
5
6
7
8
9
Most Painful
10
1 is Less Painful, 10 is Most Painful
How long have you been experiencing pain?
Are you pregnant?
Yes
No
Not applicable
If yes, please specify the age of pregnancy and medical certification from a Doctor
Are you lactating?
Yes
No
Not applicable
If yes, please advise our health practitioner.
What are your expectations from the therapy?
What are your goals in this treatment?
How did you hear about us?
Submit
Should be Empty: