Physical Therapy Intake Form
Patient information
Name: First name
Age :
Date of birth:
Gender: Gender
Address: Address
Occupation:
History
1. What is your reason for coming to therapy today?
Specify below:
2. When did your problem begin?
Specify below:
3. How did your problem start?
Specify below:
4. Please circle the appropriate answer:
a) Do you have high blood pressure?
Yes No
b) Do you currently have an infection?
Yes No
c) Do you have diabetes?
Yes No
d) Do you currently have heart trouble?
Yes No
e) Do you have asthma?
Yes No
f) Do you currently have osteoporosis?
Yes No
g) Do you currently have active cancer?
Yes No
h) Are you pregnant?
Yes
No
NA
i) Do you have other health problems? If yes, please list:
Yes No
j) Is there anything that your doctor told you If yes, please list:
not to do?
Yes No
k) Are you currently taking any prescription If yes, please list:
or over-the-counter drugs?
Yes No
l) Are you currently taking any herbal If yes, please list:
preparations / vitamins?
Yes No
m) Are you allergic to adhesives/tape, latex, If yes, please list:
or bee stings?
Yes No
n) Have you had any surgeries? If yes, please list:
Yes No
o) Have you had physical therapy previously for the same problem?
Yes No
p) Are you receiving other treatments for this If yes, please list:
problem at this time?
Yes No
q) What kind of tests have been done for your Results:
current problem? (check if applicable)
X-Ray
CT Scan
Myelogram
Ultrasound
Other
r) Have you been hospitalized in the past year If yes, when and for how long?
for this condition?
Yes No
s) Does anyone come to your home to provide health care needs
(nursing, social work, physical/occupational/respiratory needs)?
Yes No
t) Do you have any metallic implants (i.e. If yes, please list:
pacemaker)?
Yes No
Therapist comments:
5. When is your next appointment with the doctor who sent you to us?
Specify below:
6. Pain
Do you have pain now? If yes, specify location type:
Yes No
What makes it better? What makes it worse?
Does the pain interfere with your daily life? If yes, please describe:
Yes No
Rate your pain on a scale of 0-10 (0 being no pain and 10 being the worst):Seve
0. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
None Mild Moderate Severe
7. Balance
Have you fallen in the last 6 months? How many times?
Yes No
Have you had a decrease in your activity level because of a fear of falling?
Yes No
Are you reluctant to leave your home because of a fear of falling?
Yes No
What are your goals as a result of attending physical therapy?
Please check appropriate box.
Decrease pain
Improve strength
Less difficulty with work activities
Sleep longer hours
Improve movement
Stand longer minutes / hours
Sit longer minutes / hours
Less difficulty with home activities
Return to recreational activities / sports
Other
Physical therapist signature: Date:
