Manual Therapy Physical Therapy Intake Form
Personal Information
Full Name
Date of Birth
Address
City
State
Zip Code
Phone
Email
Emergency Contact
Name
Relationship
Phone
Health Information
How did you hear about us?
What is your primary reason for seeking therapy?
When did your symptoms start?
Have you had previous treatment for this condition?
Yes
No
If yes, please specify
Allergies
Current Medications
Relevant Medical Conditions (e.g., heart, diabetes)
Pain Diagram (describe or draw location of pain)
Lifestyle
Occupation
Physical Activity Level
Is there anything else you would like your therapist to know?