Orthopedic Physical Therapy Initial Consultation Form
Patient Information
Full Name
Date of Birth
Phone
Email
Address
Referral Information
Referred By
Primary Care Physician
Injury/Condition Information
Date of Onset/Injury
Location of Problem
Description of Injury/Condition
How has this affected your activities?
Pain Assessment
Current Pain Level (0-10)
Character of Pain (sharp, dull, ache, etc.)
Pain Pattern (better/worse with...)
Medical History
Past Medical Conditions
Current Medications
Allergies
Previous Surgeries
Functional Status
Work Status
Working
Modified
Not Working
Functional Limitations
Patient Goals