Sending Patient
Intake Form

PATIENT INTAKE FORM


REFERRAL INFORMATION

During this calendar year (2020), have you had any of the following Rehabilitation Services?

INSURANCE INFORMATION

 


CONFIDENTIAL PATIENT INFORMATION

Personal health history
General current conditions

(Please read all and check all that apply to you)
Recent
Diagnosed Condition
Describe your habits
Specific Body Pain
Specific Current Conditions
0 Feel Great
1 - 2 Annnoying
3 - 4 Nagging Pain
5 - 6 Hurts even more
7 - 8 Intense Horrible
9 - 10 Unbearable

PAIN DRAWING*
Click or highlight the body part that is painful.

PHYSICAL THERAPY ATTENDANCE POLICY

Cancellation and Missed Appointment Policy

I have read, understand, and agree to follow the above Cancellation and Missed Appointment Policy.