Spine and Back Rehabilitation Intake Form
Personal Information
Full Name
Date of Birth
Phone
Email
Address
Referring Physician
Physician Name
Physician Contact
Presenting Complaint
Briefly describe the reason for your visit
Location of pain/discomfort
Duration of symptoms
What makes it worse?
What makes it better?
Medical History
Relevant medical conditions
Previous surgeries (especially spine/back)
Current medications
Allergies
Pain Assessment
Pain level (0-10)
Type of pain
Sharp
Dull
Aching
Burning
Stabbing
Other
Mobility and Function
Activities limited by pain
Do you use any assistive devices?
Additional Notes
Anything else you would like to share?