Patient Intake / Medical History Form

First Name

Last Name

Date

Date of Birth

Preferred pronouns

What is the CHIEF complaint that brings you here today*

Please click on each image below to indicate location(s) of PAIN.

TODAY

PRIOR TO TODAY

Please click on each image below to indicate where you feel NUMBNESS or TINGLING.

TODAY

PRIOR TO TODAY

Please Rate your current pain levels on a scale of 0-10. 0 is no pain while 10 is worst pain imaginable.

What activities, postures or positions INCREASE your pain?

What makes your pain LESS bad?

Since its initiation, have your symptoms:

Any other changes in symptoms?

Have you experienced these symptoms previously?

No
Yes

Please Explain

What do you think originally caused your pain?

Have you had any diagnostic tests done for your current injury? (e.g. MRI, X-ray, etc)

Yes
No

If yes, what test(s)?

Please list 3-4 activities that you are currently experiencing difficulty with. Be sure to include any “high level” activities that you would ultimately like to return to.

Under each activity, check the number that best correlates to the current level of difficulty you experience with each activity. *This is required for many insurance companies, so please take a moment to complete.

Activity #1

Current level of difficulty you experience with this activity

Activity #2

Current level of difficulty you experience with this activity

Activity #3

Current level of difficulty you experience with this activity

Activity #4

Current level of difficulty you experience with this activity

Is your injury a result of a motor vehicle accident?

Yes
No

Have you had surgery recommended to you?

Yes
No

Have you had any past surgeries?

Yes
No

If yes, please explain.

Are you taking any medications?

Yes
No

If yes, please list them.

Are you pregnant?

Yes
No

If yes, how many weeks?

Are you currently under the care of a physician, chiropractor, or other health care provider other than your Primary Care Physician?

Yes
No

If yes, please list them.

What is the name of your Primary Care Physician and their clinic?

When was your last physical exam with your Primary Care Physician?

What are your goals for physical therapy?

Is there anything else you would like for us to know?

How did you hear about us?

Other - Please Explain

What is the best method for us to communicate with you? (To remind you of upcoming appointments, schedule future appointments, send exercises, etc.)

Email

Phone

Date

Consent

Check here if you're signing for an underage patient

Date

Additional Information

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