"New Client Intake Form - Stamford Physical Therapy"

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New Client Intake Form
Name
Date of Birth
Age
Address
City
ST
ZIP
Home Phone
Work Phone
Cell Phone
Email
Preferred Contact Method
Home
Work
Cell
Email
Primary Care Physician
Referral Source
Diagnosis (If Known)
Medical History (Accidents, Injuries, Falls, Surgeries) Including Dates, If Known
Current Medications
Tests (MRI, X-Ray) & Findings
Do You Smoke?
How Often?
Do You Get Headaches?
How Often?
Problem Area(s)
Chief Complaint
Rate Your Chief Complaints In Order Of Severity ( 1= Least 10=Worst )
Loss of Function
Loss of Motion
Pain
Stiffness
Swelling
Page of
www.StamfordPT.com
New Client Intake Form
Name
Date of Birth
Age
Address
City
ST
ZIP
Home Phone
Work Phone
Cell Phone
Email
Preferred Contact Method
Home
Work
Cell
Email
Primary Care Physician
Referral Source
Diagnosis (If Known)
Medical History (Accidents, Injuries, Falls, Surgeries) Including Dates, If Known
Current Medications
Tests (MRI, X-Ray) & Findings
Do You Smoke?
How Often?
Do You Get Headaches?
How Often?
Problem Area(s)
Chief Complaint
Rate Your Chief Complaints In Order Of Severity ( 1= Least 10=Worst )
Loss of Function
Loss of Motion
Pain
Stiffness
Swelling
Page of
www.StamfordPT.com
New Client Intake Form
Describe When And How The Problem Began
Describe What Makes Your Symptoms / Pain Worse
Describe What Makes Your Symptoms / Pain Lessen
Describe How This Has Affected Your Daily Life (Job / Exercises)
Do You Wake With Pain?
When?
How Often?
In What Positions(s) Do You Sleep? (Check All That Apply)
Stomach
Back
Left Side
Right Side
Have You Had Previous Or Similar Occurrences Of These Symptoms?
Have You Had Previous Treatments?
Describe When And If Possible, What Helped To Alleviate Your Symptoms
Do You Exercise Regularly?
How Many Days Per Week?
How Many Minutes Per Day?
Describe The Types Of Exercises
Describe How Your Physical Activities Changed Recently And Why
How Long Do You Sit On A Daily Basis (Hrs)?
Occupation
Describe Your Goals And Expectations From Physical Therapy
Direct Access Law Notice of Advice: Connecticut State Law Permits Direct Access For People To Receive Physical Therapy
Services Without Needing A Physician Prescription Or Referral. The Guidelines Of This Law Are:
(1) You May Have Physical Therapy For 6 Visits Or 30 Days, Whichever Is Earlier, At Which Point You Will Need A Physician's
Referral In The Event That The Person Receiving Treatment Does Not Demonstrate Objective, Measurable And Functional
Improvement. (2) Physical Therapists Cannot Diagnose Disease. (3) Although The Law Recognizes Your Right To Have Freedom
Of Choice In Health Care, Your Health Insurance Provider May Require A Physician Referral Or Prescription In Order To Cover The
Services, Should You Choose To Submit Your Bills.
“I Have Read And Understand The Guidelines Of Direct Access As Stated In The Notice Of Advice”
Name of Patient Or Guardian
Check Box If Patient Is A Minor Or Otherwise Unable To Sign Below
Signature
Date
Clear Form
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