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CLIENT INTAKE FORM
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
What is your Gender?
*
Male
Female
Insurance (NOT REQUIRED FOR SERVICE)
Primary Care Physician (Name and phone number)
Last visit with PCP
Reason for seeking physical therapy
*
Current Medical History:
*
NONE
Anemia
Asthma
Bleeding Disorders
Cancer
Chest Pain
Cardiac (Heart) disease
Communicable Disease (HIV, HPV, MRSA, etc.)
Depression
Diabetes
Dizziness
Epilepsy (Seizures)
Gout
Headaches
High Cholesterol
Hypertension
Irregular or Rapid Heart Beat
Joint replacement/Metal Implant
Kidney Problems
Osteoporosis
Motor Vehicle Injury
Pacemaker/Defibrillator
Psychiatric disorder
Stroke
Work Injury
Other
Are you experiencing any of the following?
*
NONE
Productive Cough
Fever/Chill
Coughing up blood
Night Sweats
Nausea/Vomiting
Chest pain
Trouble breathing
Joint pain
Joint stiffness
Rash or skin changes
Visual changes
Hearing Changes
Constipation
Bloody Stools
Difficulty or pain with urination
Incontinent bladder
Incontinent bowel
Other
Current Medications
*
Do you have any medication allergies?
*
Yes
No
Not Sure
Do you use or do you have history of using tobacco?
*
Please Select
Yes
No
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Do you exercise?
*
Yes
No
Emergency Contact
Name & Phone Number
Upload any important medical documents you would like for us to have
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What date is your first availability for an evaluation?
-
Month
-
Day
Year
Date
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