New Patient Intake Form

New PATIENT/CLIENT INTAKE FORM

Please fill out this page once you have scheduled your Initial Evaluation with Therapeutic Connection!

We can't wait to hear from you and get you started on your healing journey!

Name

First Name(required)

Last Name(required)

Email(required)

Phone

Address

Why are you seeking Physical Therapy?(required)

Which activities / or “inactivities” bring about your pain? How long does it take to perform that activity before the pain comes on? How long does it take to resolve?

Example: It bothers me the most when I'm getting out of bed in the morning, it usually lasts for about 20 minutes and then I'm good until the next morning.

Which activities/positions relieve your pain?

Do your symptoms fluctuate by the time of day, or more by what activities you are performing throughout the day?

Example: My symptoms are worse at the end of day. Example: It hurts every time I turn my head to change lanes while I'm driving

Is your pain constant throughout the day? If yes, rate the intensity of pain throughout the day

1 is no pain 10 is call 911 Example: My pain is 4 out of 10 when I wake up, but by the time I've been at work all day I get home, it goes up to an 8 out of 10. Example: My pain is a 3 reaching up with my right arm, but it's a 6 if I reach for my back pocket.

Please list any medications you are taking for pain, and how often you take the medications. How effective are the medications?

Example: I take 600mg ibuprofen twice daily. My pain is 8 out of 10 when I wake up, but after taking 600mg ibuprofen it goes down to a 4.

Please list any other medications that you take for any other condition

Have you had any MRI, x-ray or other diagnostic medical testing performed? When and what were the results if you know?

How long ago did your symptoms begin? Was there a specific injury? Please describe.

Have you experienced any of the following: numbness / tingling, headaches, chest pain, dizziness, symptoms that radiate away from the area of injury?

Have you had a recent physical examination from your doctor? Please list the findings if significant.

Do you have other areas of injury or pain, other than the one you are seeking treatment for?

Have you had any previous Physical Therapy for this condition? If so what was your experience, for example, did it improve, worsen, stay the same?

What activities are you not able to perform that you would like to be doing if you weren't in pain when you do them? What do you want to be able to do once your injury resolves?

What are your job or sport/activity requirements or goals?

Example: I need to spend at least 2 hours a day gardening, or, I need to lift 50# bags of dog food, or, I need to return to paddle practice.

Do you exercise regularly? If so, what do you do for exercise? If you are unable to perform your regular exercise regimens, what do they usually look like?

Example: I walk for 45 minutes every day but currently have too much pain with walking to perform.

Please include any other details you want the Physical Therapist to review prior to your visit.