For your convenience, we have provided downloadable versions of our intake forms below. To expedite your intake process, print and complete these forms and bring them with you to your initial appointment. Our online forms are provided in Adobe PDF format for easy viewing and printing using the free Adobe Reader. If you are unable to view the forms, you may need to download Adobe Acrobat for free by clicking on the Adobe icon below.
New Patient Intake Forms
- Patient Registration: Click here to Download
- Patient Medical History & Pain Diagram
- Attendance Policy
- Terms of Acceptance Form
- New Patient Checklist
Before Your Visit:
Make a list of any questions that you might have, so that you can make the best use of your time.
Write down any symptoms you’ve been having and for how long. If you have more than one symptom, begin with the one that is the most bothersome to you.
Make specific notes about your symptoms. For example, types of pain (nagging, shooting, pins and needles, aching, etc.)
- Muscle Spasm or tightness or stiffness or muscle weakness, etc. pain or other symptom?
- Better or worse with certain activities or movements or with certain positions, such as sitting or standing?
- More noticeable at certain times of day: Morning, Afternoon or Evening.
- Relieved or made worse by resting?
If available, bring any x-ray, MRI, CT-Scan or other diagnostic reports from your physician or health care professional who have treated you for your current condition.
Make a note of any important personal information, including recent stressful events in your life.
Write down and describe any injuries, incidents, or environmental factors that you believe might have contributed to your condition.
Make a list of any medical conditions of your parents or siblings.
Make sure you can see and hear as well as possible. If you wear glasses, take them with you. If you use a hearing aid, make certain that it is working well, and wear it. Tell your physical therapist and clinic staff if you have a hard time seeing or hearing. For example, you may want to say, “I have difficulty hearing. It’s helpful to me when you speak slowly.”
If available, bring any lab or diagnostic reports from other health care professionals who have treated you for your current condition.
Bring a list of the names of your physician and other health care professionals that you would like your physical therapist to contact regarding your evaluation and your progress.