Initial Intake Form - Advanced Health & Physical Therapy Solutions, LLC

Initial Intake Form
- Name*
  First Last
- Birthday*
  MM slash DD slash YYYY
- Gender*
  
  Male
  
  Female
- Address*
  Street Address Address Line 2 City State ZIP Code
- Email
- Phone (Cell)
- Phone (Other)
- Cell Phone Provider (Unless Home Phone)
- Preferred Contact Method
  Select All
  Regular Mail
  e-Mail
  Phone
- # Children/Ages
- Marital Status
  
  Single
  
  Married
  
  Divorced
  
  Widowed
- Occupation
- Employer
- Work Phone
- Insured's Name
  First Last
- Insured's DOB
  MM slash DD slash YYYY
- Relation to Insured
- Who referred you to us?
- How else did you hear about us?
- What is your major complaint?
- When did the condition begin?
  MM slash DD slash YYYY
- What do you think caused this condition?
- Please describe the nature of the pain (Check all that apply)
  Dull Ache
  Sharp Stabbing
  Burning
  Pins/Needles
  Numbness
  Radiatnig
- Associated Symptoms
  Swelling
  Stiffness
  Clicking
  Locking
  Bucklng
  Weakness
  Difficulty Using Stairs
  Difficulty Walking
- Is your present complaint due to a motor vehicle/workers comp accident?
  
  Yes
  
  No
  
  Unsure
- Date of Accident
  MM slash DD slash YYYY
- Insurance Company & Claim Number
- If so, please describe the accident:
- Upload Police Report or Other Documentation Related to the Accident
  Max. file size: 100 MB.
- Have you had this or a similar condition in the past?
- Do any positions make it feel worse?
- Do any positions make it feel better?
- Is this condition:
  
  Improved
  
  Unchanged
  
  Getting Worse
- Is this condition interfering with your... (Check all that apply)
  Work
  Sleep
  Exercise
  Daily Routine
- Have you consulted any other physicians for THIS condition:
  
  Yes
  
  No
- What physicians/therapists have you seen for this condition:
- Have you had any of the following imaging studies for your problem? (check all that apply)
  X-Ray
  CT Scan
  MRI
  Other
- Have you taken any medications for this problem?
  
  Yes
  
  No
- If Yes, what medications?
- Have you had previous treatments/surgeries for this problem?
  
  Yes
  
  No
- If yes, what treatments/surgeries?
- Family History: (Include relation and age of onset if known)
  High Blood Pressure Diabetes Meliltus Heart Disease Stroke Cancer Arthristis Osteoporosis Asthma COPD Other
- Mental Work
  
  Heavy
  
  Moderate
  
  Light
- Hours Per Day
- Physical Work
  
  Heavy
  
  Moderate
  
  Light
- Hours Per Day
- Activity Level (Exercise)
  
  INACTIVE (normal activities of daily living)
  
  LIGHT (some activity; walking, gardening, occasional weekend recreational exercise)
  
  MODERATE (regular 3x per week moderate exercise, weekend athletics)
  
  VIGOROUS (regular 3-5x per week vigorous exercise and/or athletics weekly)
  
  INTENSE (competitive daily vigorous sports training)
- Smoking History
  
  Current
  
  Previous
  
  Never
- Cigarettes Per Day / Number of Years
- Alcohol Consumption
  
  Beer
  
  Liquor
  
  Wine
  
  None
- Servings Per Week / Number of Years
- Are you currently taking any medication?
  
  Yes
  
  No
- List Medications you Currently Take
  Medication name Dosage Directions
- Do you have any allergies?
  
  Yes
  
  No
- List Allergies
  Food Environmental Medication
- Upload Any File Relating to this Injury/Condition (only jpg, gif, png, pdf, zip files allowed)
  
  Drop files here or
  
  Accepted file types: jpg, gif, png, pdf, zip, Max. file size: 100 MB, Max. files: 10.
Save and Continue Later

High Blood Pressure	Diabetes Meliltus	Heart Disease	Stroke	Cancer	Arthristis	Osteoporosis	Asthma	COPD	Other

Medication name	Dosage	Directions

Food	Environmental	Medication