New Patient Intake Form

FULL NAME *

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Home Phone: *

Cell Phone:

Date of Birth: *

Gender identity: *

Marital Status:

MSDW

Emergency Contact: *

Phone: *

How did you hear about Chris Michels Physical Therapy?:

If Family/Friend or Other please list:

Employment Status: *

Employer:

Phone:

Accident/Injury Date:

Accident or Injury

AccidentInjury

Describe your accident/injury:

What are your main complaints that you would like help with: *

Where your symptoms are located and what type of pain you have been experiencing: *

Examples- Stabbing, Burning, Pins & Needles, Numbness

Please list any surgeries you have had:

Please list any current medications (prescribed and over the counter):

Are you allergic to any medications, tapes or lotions?:

YesNo

List allergies: *

What are your symptoms:

ImprovingBecoming WorseStaying the Same

Select activities you have trouble with because of this injury:

SittingRisingBendingDrivingStandingTurningWalkingStairsLyingSleepingGroomingHouseworkAthleticsOther

List Other activities:

What makes it feel better:

What makes it feel worse:

Do your symptoms disturb your sleep?:

YesNo

# of hours restful sleep:

Do your symptoms change when you cough or sneeze?:

YesNo

Have you had any of the following Medical or Rehabilitative Services for this Injury / Episode?:

Physical TherapyNaturopathic DoctorChiropracticEmergency Room CareMassage TherapyAcupunctureCT ScanMRIBone ScanX-Rays

Do you have or have you ever had any of the following?:

Asthma, Bronchitis, or EmphysemaShortness of Breath / Chest PaiHeart Disease or AnginaHigh Blood PressureHeart Attack or Heart SurgeryStrokeCongestive Heart FailureBlood Clot / EmboliEpilepsy / SeizureThyroid DiseaseWeight Loss / FatigueHerniaVaricose VeinsAllergiesPins or Metal ImplantsShoulder Injury or SurgeryJoint Replacement SurgeryElbow/Hand Injury or SurgeryBack Injury or SurgeryKnee Injury or SurgeryLeg/Ankle Injury or SurgeryCurrently PregnantTobacco UseFibromyalgia / Chronic Pain

Please list any other information that you believe would assist me in your care:

Are you aware of your diagnosis and prognosis as explained by your doctor?:

YesNo

What are your goals with Physical Therapy?:

Patient / Guardian Signature: *Please sign below by entering your full name.

Date: *

Fieldset

Accident/Injury Information

Medical Information

Functional Capability

Verification