Aquatic Physical Therapy Intake Form
Personal Information
Full Name
Date of Birth
Phone Number
Email Address
Address
Emergency Contact Name
Emergency Contact Phone
Medical History
Primary Diagnosis / Reason for Therapy
Referral Physician (if any)
Relevant Medical Conditions (please specify)
Current Medications
Allergies
Prior Surgeries (relevant to therapy)
Do you have any of the following? (check all that apply):
Heart Condition
High Blood Pressure
Respiratory Issues
Diabetes
Seizures
Open Wounds/Infections
Other
If you checked "Other," please specify:
Aquatic Therapy Considerations
Are you comfortable in water?
Yes
No
Unsure
Do you require assistance entering/exiting a pool?
Yes
No
Swimming ability
Non-swimmer
Beginner
Intermediate
Advanced
Use of assistive devices (please specify, if any)
Explain any limitations in movement or balance
Goals for Aquatic Physical Therapy
Additional Comments
Anything else we should know?