Physical Therapy Intake Form - Stamford Physical Therapy
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2New Client Intake Form
Name
Date of Birth
Age
Address
City
ST
ZIP
Home Phone
Work Phone
Cell Phone
Email
Preferred Contact Method
Home
Work
Cell
Email
Primary Care Physician
Referral Source
Diagnosis (If Known)
Medical History (Accidents, Injuries, Falls, Surgeries) Including Dates, If Known
Current Medications
Tests (MRI, X-Ray) & Findings
Do You Smoke?
How Often?
Do You Get Headaches?
How Often?
Problem Area(s)
Chief Complaint
Rate Your Chief Complaints In Order Of Severity ( 1= Least 10=Worst )
Loss of Function
Loss of Motion
Pain
Stiffness
Swelling
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Parent category: Business