FMS Intake, History & Goals

TODAY'S DATE

Date

PRIMARY CARE PHYSICIAN

Patient's Last Name

First

Middle

What would you prefer to be called?

Address

Street Address

Street Address Line 2

City State

Zip Code

Sex

Male Female

Home Phone

Work Phone (extension)

Cell Phone

Age

Date of Birth

Date

How would you like us to keep in touch with you?

Snail Mail

Email Address

example@example.com

Have you EVER been diagnosed as having any of the following conditions?

Heart Problems

Yes No

High Blood Pressure

Yes No

Pacemaker

Yes No

Rheumatoid Arthritis

Yes No

Other Arthritic Condition

Yes No

Stroke

Yes No

Lung Disease

Yes No

Asthma

Yes No

Diabetes

Yes No

Epilepsy/Seizures

Yes No

Hearing Loss / Disorder

Yes No

Eye Disease

Yes No

Muscular Disease / Disorder

Yes No

Multiple Sclerosis

Yes No

Tuberculosis

Yes No

Circulation Problems

Yes No

Hepatitis

Yes No

Kidney Disease

Yes No

Implanted Devices

Yes No

Cancer

Yes No

Osteoporosis

Yes No

Depression

Yes No

Past Pregnancy

Yes No

Currently Pregnant

Yes No

Chemical Dependency

Yes No

Other:

Date

Surgery/Injury/Condition

Reason

Date

Surgery/Injury/Condition

Reason

Date

Surgery/Injury/Condition

Reason

Date

Surgery/Injury/Condition

Reason

Please list any concerns regarding your movement patterns and/or the fitness and movement goals that you'd like to achieve:

The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to Onondaga Physical Therapy, LLC. I understand that I am financially responsible for any balance that is unpaid by my insurance company. I understand Onondaga Physical Therapy will impose a late fee of $25 for any balance that is older than 90 days, unless I have prior payment arrangements. I further authorize Onondaga Physical Therapy, LLC and my insurance company to release any information that is required to process my claims. Ihereby consent to treatment procedures and patient care which in the judgment of my therapist and/or physician may be considered necessary or advisable while I am a patient of Onondaga Physical Therapy,

I hereby authorize the use or disclosure of my individually identifiable health information as described in the NOTICE OF PRIVACY PRACTICES I received.

PATIENT/GUARDIAN SIGNATURE

DATE

Date

ONONDAGA PHYSICAL THERAPY

Functional Movement Screen

Medical History & Movement Goals

Please list any surgeries or other medical conditions for which you have been treated. Only respond to as many as you need to.