Post-Surgical Physical Therapy Intake Sheet
Patient Name
Date
Date of Birth
Phone Number
Address
Email
Surgical Information
Date of Surgery
Surgical Procedure
Surgeon's Name
Hospital/Facility
Post-Surgical Precautions/Restrictions
Medical Information
Diagnosis
Current Symptoms
Current Medications
Relevant Medical History
Goals & Expectations
What are your goals for physical therapy?
Expectations from Treatment
Additional Information
Mobility Aids Used
Allergies
Other Information