2716 Ocean Park Blvd, Suite 1065

Santa Monica, California 90405

Tel: (310) 591-8016 Fax: 888 853-0707

PATIENT INFORMATION FORM

Last Name: ______________________________________ First Name: __________________________________________

Address: _____________________________________________________ Apt./Suite #: __________________________

City: ______________________________________________ State: ______________ Zip: ________________________

Home Tel: ____________________________________ Cell: ____________________________________

DOB: _______/_______/___________ Age: _____________ Gender: Male Female

Relationship status: Married Single Divorced Separated Widowed

Student Status: Not a Student Full-time Part-time

Occupation: ____________________________________________ Employer: ___________________________________

Work Tel: _____________________________________ Email: _______________________________________

Referred by: ___________________________________ Tel: _________________________________________

Physician Name: ________________________________ Tel: _________________________________________

Address: _______________________________________ City: _______________________ State: ______ Zip: _______

GENERAL HEALTH INFORMATION

Are you currently under a physician’s care? Yes No If yes, please explain: __________________________________

_______________________________________________________________________________________________________

Are you currently taking medication, vitamins and/or supplements? Yes No If yes, please list: ___________________

_______________________________________________________________________________________________________

Any personal or family history of systemic illness (Diabetes, cancer, heart disease, blood disorders, neural symptoms, etc.)?

_______________________________________________________________________________________________________

Are you allergic to any of the following? Aspirin Penicillin Codeine Latex Sulfa Drugs Season Allergies

Other ______________________________________________________________________________________________

Do you smoke/vape/use tobacco products? Yes No If yes, what type? ____________________________________

Do you have difficulty sleeping due to pain? Yes No What position do you sleep in? Back Stomach Side
 FOR WOMEN ONLY:

Are you pregnant or trying to get pregnant? Yes No Do you take oral contraception? Yes No

At what age did you begin your menstrual cycle? _________ Is your menstrual cycle regular? Yes No

If NO, please explain____________________________________________________________________________

Have you ever had a stress fracture? Yes No If yes, please describe: ___________________________

Have you ever had a bone density test (DEXA)? Yes No If yes, when? _____/____ Results: _________

INJURY INFORMATION

Injury Type Work Auto Home Sport Related Other___________________________________________

Injury Date _________________ Area(s) Being Treated: _______________________________________________________

Have you had this injury in the past? Yes No if yes, when? ________________________________________

Type of surgery: ______________________________________ Surgical Date (if appropriate): _______________________

Surgeon: _____________________________________________ Telephone: _____________________________________

Do you currently use any assistive devices(crutches, braces, orthotics)? ____________________________________________

What is your current pain at rest (0=no pain, 10=worst imaginable pain)? ___________________________________________

What is your pain with activity (0=no pain, 10=worst imaginable pain)? _____________________________________________

Prior History of Injury / Surgery Surgical Location (Body Part) Date of Injury /Surgery

I attest that all of the information reported is correct. I understand that Velocity Physical Therapy, Inc. will not bill
my insurance directly and I will undertake that responsibility directly. I also understand that there is a 24 hour
cancellation policy. If you cannot make a scheduled appointment, kindly notify us to avoid the cancellation fee.

Signature: __________________________________________ Date: ____________________________