Patients Name:___________________________________________________

Address:_________________________________________________________
City:_____________________ State__________ Zip code_________________
Date of Birth_____________________ Social Security #:__________________
Home #:________________Work #:______________ Cell #:_______________
Email:____________________________________________________________
Marital status: Married
Student:

Single

Yes / No

Widowed

Divorced

Gender: Female / Male

Employer Name:_____________________________________________________
Employer Address:___________________________________________________
City:___________________ State:____________ Zip Code:__________________
Referring Physician:__________________ Phone #:________________________
Address:_____________________________________________________________
City:___________________ State:___________ Zip code:_____________________
Purpose of Visit(DX):___________________________________________________
Have you seen another physical therapist this year?: Yes
Off work because of current episode: Yes

/ No

/ No

Since:____________________

History of Present Complaint:

Describe Relevant Symptoms:_____________________________________________
Commenced as a result of:_________________________________________________
Present Since:___________________ Improving

Unchanging

Worsening

What makes it better?:____________________________________________________

What makes it worse?:____________________________________________________
Previous Treatment:______________________________________________________
X-Ray?: Yes / No

MRI?: Yes / No

Recent or Major Surgery: Yes / No

Results:______________________

If yes, details & date:___________________

Accidents: Yes / No

If yes, details & date:_______________________________

Circle any of the following symptoms you have experienced in the past month:
Loss of appetite
Headaches
Shortness of breath
Fever
Swelling
Sweats
Bruising/Bleeding
Weakness
Numbness
Anxiety
Dizziness
Vertigo
Nausea/Vomiting
Rash
Weight loss
Lightheadedness
Chills
Change in bowel
Circle any of the following you have:
Pace maker
Diabetes
Cancer or history of malignancy

Osteoporosis

Insurance information:
Primary insurance company:____________________ Phone #:__________________
Policy Holder:______________________________ Self Spouse/partner Guardian
D.O.B:______________
SSN:______________
Phone #:__________________
Policy #:___________________________
Group #:________________________
Date:____________ Eff. date:______________
In Network
Out of Network
Deductible:__________
Ded Met?:__________
Out of Pocket:_____________
Benefits:_____% Co Insur:_____% Co-payment/fee:______ Visits per year:______
Precert/Auth required:__________________
Phone#______________________
Name of insurance rep:_______________________ Verified by:__________________
First Appt:_______________
Time:_____________ Therapist:______________
Notes:__________________________________________________________________
________________________________________________________________________
________________________________________________________________________