Welcome to our practice!
Please help us serve you better by taking a few minutes to provide
The following is very important in our evaluation process. Please fill out these forms as specifically as possible to provide us with a clear picture of your present pain and functional status.
Please shade in areas where you have pain,discomfort,or tension.
if numbness or tingling- mark with X over the area
ListALL 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
Patient Goals Please list the activities that you would like to be able to do as a result of therapy.
I understand that Physical Therapy Studio 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 initial evaluation, progress evaluation and discharge summary 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.
I do hereby agree and give my consent for Physical Therapy Studio to furnish care and treatment that is considered necessary and proper in the 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.