New Patient Information Sheet

New Patient Information Sheet
Please help us serve you better by taking a few minutes to provide the following information
Last Name*
First Name*
Today's date:*

MonthDayYear
Date

The following is very important in our evaluation process. Please fill out these forms as specifically as possible.
What is the primary issue/problem that brings you in today?
Secondary concern/problem?
As a result, I am now having difficulty with:
Are you currently experiencing pain as a result of these symptoms? If yes, what is it like?
When did your symptom(s) begin? (Date):

MonthDayYear
Date

Please rate your pain in the last 24-72 hours

Using the “0 -10” scale where 0 is no pain and 10 is the worst possible pain.
At its worst (0-10)
Description
At its best (0-10)
Description
At present (0-10)
Description
At night (0-10)
Description

At what time of day are your symptoms the worst?
At what time of day are your symptoms the best?
What activities increase your pain?
What activities decrease your pain?
What other types of treatment have you had for this problem?

MassageBodyworkPhysical TherapyMyofascial ReleaseChiropracticSurgery
Other Medical Treatment: (please describe)

List past medical history and dates of occurrence. Include surgeries, accidents and other traumas.Others (explain below)
List ALL medications which you are currently taking, the condition for which you are using them, the dose, and their effectiveness. (Include supplements, herbal and homeopathic remedies).
Medication
For treatment of
Dose / Amount per day
Effectiveness
Medication
For treatment of
Dose / Amount per day
Effectiveness
Medication
For treatment of
Dose / Amount per day
Effectiveness
Medication
For treatment of
Dose / Amount per day
Effectiveness
Medication
For treatment of
Dose / Amount per day
Effectiveness

List all the Tasks / Activities that you have difficulty performing and your tolerance (minutes/hours). If you are no longer able to perform an activity, your tolerance would be “0”.
Task / Activity
Tolerance (minutes/hours)
Task / Activity
Tolerance (minutes/hours)
Task /Activity
Tolerance (minutes/hours)
Task / Activity
Tolerance (minutes/hours)
Task / Activity
Tolerance (minutes/hours)

Patient Goals Please list the activities that you would like to be able to do as a result of therapy.
Task / Activity*
Duration / How Often*
By when?*
Task / Activity
Duration / How Often
By when?
Task / Activity
Duration / How Often
By when?
Task / Activity
Duration / How Often
By when?
Task / Activity
Duration / How Often
By when?
Other Goals

Informed Consent
I understand that Physical Therapy San Pedro will maintain my privacy to the

highest standards and may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment.

Photographs taken during the duration of treatment will be used for postural comparison purposes and as educational tools. By signing below, I consent to the use of these photographs in a professional manner.
Patient/Parent/Guardian
Printed Name*
Date*

MonthDayYear
Date
Signature:*

Clear
In addition, photographs and video will be used as educational tools for website and social media purposes. By signing below, I consent to the use of these photographs in this manner.
Patient/Parent/Guardian Printed Name:
Printed Name*
Date*

MonthDayYear
Date
Signature*

Clear
I do hereby agree and give my consent for Physical Therapy San Pedro to furnish

care and treatment that is considered necessary and proper in diagnosing or treating of my physical condition.

I understand that I retain the right to revoke this consent by notifying the practice in writing at any time.
I hereby certify that all the above information is true to the best of my knowledge.
Patient/Parent/Guardian
Printed Name:*
Date:*

MonthDayYear
Date
Signature*

Clear

Reassignment of Benefits