Information Intake form

Physical Therapy Studio

Information Intake
Welcome to our practice!

Please help us serve you better by taking a few minutes to provide
Name*

First NameLast Name
Today's date:

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth
Age
Cell Phone number

Area CodePhone Number
Home Phone number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Email:*
example@example.com
Marital Status

MarriedSingle

Emergency contact

First NameLast Name
Phone Number for Emergency contact

Area CodePhone Number
Employer:
Occupation:
Primary Care Physician(PCP)
Phone Number for PCP

Area CodePhone Number
Specialist Physician name
Phone Number for Specialist Physician

Area CodePhone Number

How did you hear about our practice?
Who can we thank for referring you to our practice?
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.
What is the primary issue/problem that brings you in today?
Secondary concern/problem?
As a result, I am now having difficulty with

Please shade in areas where you have pain,discomfort,or tension.

if numbness or tingling- mark with X over the area
Draw on Image
Are you currently experiencing pain as a result of these symptoms? If yes,what is it like?
Please rate your pain in the last 24-72 hoursUsing the "0-10"scale where 0 is no pain and 10 is the worst possible pain
At it's worst
At it's best
At present
Night (sleeping)
When did your symptom(s) begin?(date:)
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?

List past medical history and dates of occurrence. Include surgeries, accidents and other traumas
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.

List ALLmedications 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 Name	For treatment of:	Dose/amount per day	Effectiveness
Medication
Medication
Medication
Medication
Medication

Goals: Please list the activities that you would like to be able to do as a result of Physical Therapy

	Task/Activity	Duration/How Often	By When
Activity
Activity
Activity
Activity
Activity

Other Goals?
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.
Patient/Parent/Guardian Signature:*

Clear
Date:

MonthDayYear
Date
Should be Empty:

Physical Therapy Studio

Please rate your pain in the last 24-72 hoursUsing the "0-10"scale where 0 is no pain and 10 is the worst possible pain