Patient Therapy Patient Intake Form
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1Physical Therapy Intake Form
Personal Information
Name:
Date:
Address:
Phone:
Email:
DOB:
Sex:
Who referred you?
History
Exercise Frequency:
Exercise Type(s):
Do you smoke?
Have you ever smoked?
How Often?
Are you pregnant?
Do you have a Pacemaker?
Allergies:
What medications are you currently using?
Previous complaints/surgeries:
Previous diagnoses/medications:
Complaint
What is your major complaint?
Start Date:
Possible Cause:
Symptoms:
Previous doctors seen for complaint:
Previous treatment for complaint:
Symptom-Aggravating Factors:
Symptom-Relieving Factors:
Time of Day Symptoms are Best:
Time They Are Worst:
Current Duration of Pain:
Intermittent
Constant
With Certain Motions
Current Level of Pain:
Mild
Moderate
Severe
Excruciating
Is your pain getting better or worse?
Have you had this injury before?
Do You Have Any of the Following Today? (Check All That Apply)
AIDS/HIV
Anemia
Angina
Arteriosclerosis
Arthritis
Asthma
Blood Clots
Bone Infection
Cancer
Chemical Dependency
Circulation Problems
Depression
Diabetes
Epilepsy
Eye Infection
Heart Problems
Hemophilia
High/Low Blood Pressure
Joint/Bone Infection
Liver Problems
Lung Issues
Multiple Sclerosis
Musculoskeletal Problems
Pneumonia
Stroke
STD
Tuberculosis
Urinary Infection
Mark Areas of Discomfort
Signature
Date
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Parent category: Business