Geriatric Physical Therapy Intake Form
Patient Information
First Name
Last Name
Date of Birth
Age
Address
Phone
Email
Emergency Contact
Name
Phone
Relationship
Medical History
Primary Diagnosis
Past Medical Conditions
Current Medications
Allergies
Mobility & Functional Status
Assistive Devices Used
Describe Mobility (e.g. walking, transferring)
Assistance Needed with Daily Activities
Presenting Complaints / Goals
Current Complaints
Goals for Physical Therapy
Other Notes