Workers’ Compensation Physical Therapy Intake Form
Patient Information
Full Name
Date of Birth
Address
Phone Number
Email
Emergency Contact Name
Emergency Contact Phone
Employer & Insurance
Employer Name
Employer Phone Number
Insurance Company
Adjuster Name
Claim Number
Adjuster Phone
Injury Information
Date of Injury
Body Part(s) Injured
Describe how the injury occurred
Have you had prior physical therapy for this injury?
Yes
No
Physician Information
Referring Physician
Physician Phone
Additional Information
List current medications
Any allergies?
Other relevant medical history
Additional Comments