Physical Therapy Intake Form - Flow PT and Pilates in Asheville NC

Date

Name

First Last

Date of Birth

Age

Phone (Best contact number)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Marital Status

Occupation

short description of work requirements

Emergency Contact

Emergency Contact Phone Number

Referring Provider (if there is one) and Practice Name

How did you learn about Flow Physical Therapy and Pilates?

Primary complaint OR injury (Why are you seeking physical therapy?)

Date of injury OR when you first noticed symptoms (It's OK if it's not exact)

Is this injury/problem related to an auto accident?*

Yes

If you checked yes above, is there a claim or lawsuit involved with the incident?

Yes

What activities or positions aggravate your pain?

For example: Does it hurt when sitting or standing? Going up and down stairs? Sleeping?

What eases your symptoms or makes you feel better?

For example: Sitting down feels better. Ice feels better. I am better in the morning.

Past Medical History

Please provide any past surgeries or injuries, regardless of whether they relate to the current issue, and approximate date of occurence.

Please check if any of the following apply to medical history

Pacemaker or heart disease

Active malignancy

Heart murmur

Osteopenia/Osteoporosis

Diabetes

Epilepsy/seizures

Pregnancy

If you checked yes to pregnancy above, how many weeks are you into pregnancy?

Please list any current medications and condition for which they are being taken

Please list any sports, exercise, or hobbies you do.

What are your goals for physical therapy?

Medical informed consent*

I agree to the informed consent and privacy policy.

I hereby assert that the above information is accurate and best represents why I am seeking physical therapy. I understand that Flow Physical Therapy and Pilates will maintain my privacy to the best standard. I understand that my protected health information will only be used for the purposes of executing my medical care and treatment, taking payment for services, and for any administrative functions pertaining to treatment and payment.

I do hereby give my consent for Flow Physical Therapy and Pilates to administer care that is appropriate and necessary for the evaluation and treatment of the diagnosis or physical condition. I understand that there is no guarantee that physical therapy will resolve the issue for which I am seeking treatment.

I understand that I may revoke my consent at any time by notifying the clinic in writing.

I understand that by checking the box to agree to the above statements, I am authorizing this as my signature.

Cancellation policy consent*

I agree to the cancellation policy.

I understand that in the event that I need to cancel my scheduled appointment, I will provide at least 24 hours notice from the time of the appointment. Cancellations that occur within less than 24 hours of the appointment will result in a $50 fee to cover costs of doing business. The late fee will be paid to me within 7 days of the occurrence.

Name

This field is for validation purposes and should be left unchanged.