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

Initial Intake Form
- Name*
  First Last
- Birthday*
- 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
- 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?
- 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
- Insurance Company & Claim Number
- If so, please describe the accident:
- Upload Police Report or Other Documentation Related to the Accident
- 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.
Save and Continue Later
This iframe contains the logic required to handle Ajax powered Gravity Forms.

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

Medication name	Dosage	Directions

Food	Environmental	Medication