Physical Therapy Intake Form - Tailwind Physical Therapy

Personal Information

Name *

Date *

Address *

Phone *

Email *

Date of Birth *

Sex *

Who referred you? *

History

Exercise Frequency *

Exercise Type(s) *

Do you smoke? *

Yes

No

Have you ever smoked? *

Yes

No

How often?

Are you pregnant? *

Yes

No

Do you have a pacemaker? *

Yes

No

Allergies: *

What medications are you currently using? *

Previous complaints/surgeries:

Previous diagnoses/medications:

Complaint

What is your major complaint? *

Start Date *

Possible Cause

Symptoms: *

Previous doctors seen for complaint: *

Symptom-Aggravating Factors: *

Symptom-Relieving Factors: *

Time of Day Symptoms are Best: *

Time of Day Symptoms are Worst: *

Current Duration of Pain

Intermittent

Constant

With Certain Motions

Current Level of Pain

Mild

Moderate

Severe

Excruciating

Is your pain getting better or worse? *

Have you had this injury before? *

Yes

No

Do you have any of the following today?

Describe Areas of Discomfort:

Emergency Contact Information

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Phone Number *

Medical Information Release

I hereby give permission to Tailwind Physical Therapy to release medical information to:

Name *

As well as my physician(s), attorney, assignees, and/or beneficiaries.

Consent to Treat

I hereby consent to evaluation and treatment by my Physical Therapist at Tailwind Physical Therapy. I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examinations, test results, diagnoses, treatment, and any plans for future care of treatment. I understand and have been provided with a Notice of Privacy Practices that provides a more complete description of information uses and disclosures, I understand that I have the right to review the notice prior to signing this consent.

Check the boxes next to each statement to confirm your consent:

Cancellation & No Show Policy

In respect of our therapists' time and 1-hour appointment slots, *

I acknowledge that I am responsible for making all appointment changes a minimum of 24 hours in advance of my scheduled appointment

I agree to provide a credit card on file to be charged a $50 fee in the event of a no show or late cancellation

Digital Signature *

Date *

Thank you for submitting your form online. It has been sent.

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Personal Information

History

Complaint

Do you have any of the following today?

Emergency Contact Information

Medical Information Release

Consent to Treat

Cancellation & No Show Policy

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