Patient Intake Form
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1
2Great
B asin
P hysical
T herapy
a nd
P erformance
C enter
Pa#ent
I ntake
F orm
Patient
Last Name:
_____________________________________________
First Name:
________________________________
DOB:
___________ ____________ ____________
/
/
Age:
_______
DATE:
____________________________________
Occupation:
_______________________________________________________________________________________
Date of Injury:
_____________________________________
Date of Surgery:
__________________________________
☐
☐
☐
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Yes
No Are you currently pregnant?
Yes
No
Are you receiving Home Health Care?
What caused your current problem?
______________________________________________________________
_________________________________________________________________________________________________
☐
☐
Have had this problem before?
Yes
No
If Yes when and where?
_____________________________
_________________________________________________________________________________________________
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☐
Have your symptoms gotten worse?
Yes
No
What makes your symptoms better?
______________________________________________________________
What makes your symptoms worse?
______________________________________________________________
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☐
☐
Are you able to sleep with this problem?
Yes
No
Sometimes
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☐
☐
☐
Is your pain worse in the:
Morning
Midday
Evening
All day
List all medications you are currently taking:
_______________________________________________________
_________________________________________________________________________________________________
Your pain: Draw the areas of pain ( / / / / ) ; tingling (XXXX) ; numbness ( > > > > )
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