Orthopedic Physical Therapy Intake Form
Personal Information
First Name
Last Name
Date of Birth
Phone
Email
Address
Insurance Information
Insurance Provider
Policy Number
Group Number
Referring Physician
Physician Name
Phone
Injury / Condition Information
Describe your current injury or condition
Date of Injury/Onset
How did the injury occur?
Previous treatments or surgeries related to this condition
Medical History
Please list any relevant medical conditions
Current medications
Allergies
Functional Goals
What are your primary goals for physical therapy?