Chronic Pain Physical Therapy Intake Form
Personal Information
Full Name
Date of Birth
Phone Number
Email Address
Address
Referring Provider
Provider Name
Clinic/Practice
Pain History & Description
Where is your pain located?
How long have you had this pain?
Describe the nature of your pain (e.g. sharp, dull, burning):
Pain Severity (0 - no pain, 10 - worst pain imaginable):
What makes it better or worse?
Medical History
Relevant Diagnoses
History of Surgeries related to pain
Current Medications
Allergies
Functional Impact
Which daily activities are affected?
What are your goals for physical therapy?
Other Information
Is there anything else you would like to share?