Test Form 2

Intake form

Patient Intake Form (#4)
How do you want to be addressed?
Please indicate how you identify.
Please enter patient’s date of birth
Please indicate who to call in the event of a medical emergency.
Please indicate individuals you grant access to information regarding your physical therapy treatments. Other Protected Health Information remains private unless you submit a written request.
Describe your typical activity during the week. ie. work activity, exercise, sitting periods, etc
Describe as specifically as possible the areas of your body you experience pain and when. Rate pain level from 1 to 10.