Physical Therapy Patient Intake Form
Personal Information
First Name
Last Name
Date of Birth
Phone
Email
Address
Emergency Contact
Name
Relationship
Phone
Insurance Information
Insurance Provider
Policy Number
Referral
Referring Physician
Medical History
Reason for Visit / Chief Complaint
How did the symptoms/injury begin?
Have you had physical therapy before?
Yes
No
If yes, where?
Current Medications
Allergies
Relevant Past Surgeries or Hospitalizations
Other Chronic Conditions