Sports Injury Physical Therapy Intake Form
Personal Information
Full Name
Date of Birth
Address
Phone Number
Email
Emergency Contact
Emergency Contact Name
Emergency Contact Phone
Insurance Information
Insurance Provider
Policy Number
Referral
Referred By
Injury & Medical Information
Date of Injury
Type of Sport/Injury
Briefly Describe the Injury
How did the injury occur?
Symptoms Experienced
Current Pain Level
0 - No Pain
1
2
3
4
5 - Moderate
6
7
8
9
10 - Worst Pain
Previous Treatments for This Injury
Relevant Medical History
Goals
Goals for Physical Therapy