MEDICAL INTAKE FORM

Please provide your contact information here. We want to stay connected with you regarding your appointments or may have questions regarding your insurance or benefits

Personal information

First Name *

Last Name *

Home Number

Phone *

Email *

Street Address

City

State

Country

Postal Code

What is Your Gender? *

Please Select Your Martial Status *

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone Number

Emergency Contact Relationship

How did you hear about us? *

Is your injruy related to any of the following? *

Can you explain about your injury? if it's related to any of the above

Is There Any Attorney Involved? *

Medical Information

Weight *

Height *

Tell us About your Injury or Symptoms

Description of how injury occured *

Date of Injury/Onset of Symptoms *

Diagnose stated by Physician (Type N/a - if not applicable) *

What region(s) are affected by your current symptoms? *

Have you received any previous treatment for this condition? *

Please Indicate the previous treatment you received for this condition *

Are you experiencing or have you experienced pain associated with this injury? *

What kind of pain are you experiencing? *

My Pain/Symptoms are worse *

My Pain/Symptoms are Best *

Please indicate the intensity of current, best and worst pain levels over the past 24 hour on scale of 0 (no pain) to 10 (worst pain imaginable) *

Have you ever had any of the following for this issue before? *

Have you ever had any of the following diagnostic test for this issue before? *

Have you fallen within the last year? *

Do you feel unsteady when standing or walking? *

Do you worry about falling? *

How many times have you fallen within the last year? *

Please select the conditions that you have been or are presently being treated for. This information helps your therapist develop a treatment plan that will be best for you. *

Are you currently taking any medication? *

What are your goals for therapy this time? *

Is there any other information regarding your medical history that is important for us to know? *

Insurance or Cash Pay? *

Pre Payment / Post Payment

Insurance Details

Are you a Medicare Patient? *

Are you receiving home health now or have you received it in the past 60 days?

Have you Recently Been Discharged from Home Health? *

Do you have insurance you would like to use? *

Please Complete the Following

Upload Copy of Insurance *

Insurance Plan

Policy ID *

Group ID *

Are you policy holder? *

Name of Insurance Policy Holder *

Policy Holder DOB *

Relationship to Policy Holder *

Policy Holder Gender? *

Policy Employer Name *

Do you have any additional insurance you would like to use? *

Click on Submit To Submit Your Medical Intake Form. Thank You