Finger Lakes Physical Therapy
Medical Intake Form
Name______________________________________ Date:______________________
Allergies Therapist Notes/ Comments: Arthritis
Asthma/Breathing Problem
Cancer
Cigarette History
Currently Pregnant
Diabetes
Epilepsy/Seizures
Fractures
Headaches
Heart Disease/Attack
High Blood Pressure
High Cholesterol
Metal Implants
Osteoporosis
Pacemaker
Poor Circulation
Prior Auto Accident
Psychiatric Illness
Recent Chest Pain
Scoliosis
Stroke
Swollen Feet
Thyroid Disease
Total Joint Replacement
Ulcers
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Please describe your current symptoms/ injury:_______________________________________
Date of injury___________ Have you received any previous treatment for this injury _______
If so, When?___________________ Where?___________________________
In relation to your current injury have you had: (please circle)
Nausea/ Vomiting/ Fever/ Chills/ Sweats/ Weight change/ Numbness/ Tingling/ Weakness/
Dizziness/ Night Pain/ Bowel or Bladder changes/ Surgery____________________
Any other information that you would like to share with your Physical Therapist:____________
______________________________________________________________________________
Current Medications: (Name or Type of Medication)__________________________________
______________________________________________________________________________
Therapist Signature /Date:_____________________________________________
Finger Lakes Physical Therapy
Name:_____________________________ Date of Birth:____________________
Mailing Address: If P.O. Box, please indicate street address
Phone: Home Work: Cell:
Social Security #: Insurance:
Insurance: Is the subscriber other than you: yes/ no If other than you, relationship:
Name:
THEIR date of birth: THEIR Social Security #:
Employer: Employer Address:
Is your current injury to be billed to Date of injury:
Date of injury:Worker's Compensation? yes/ no
Worker's Comp. Insurance carrier: Worker's Comp. claim #:
Is your current injury to be billed to Date of Injury:
No Fault Automobile Insurance? yes/ no
No Fault Insurance Carrier No Fault claim #:
In an Emergency please notify: Phone #:
Primary Care Physician: Referring Physician:
Date of last medical exam:
I authorize Finger Lakes Physical Therapy to provide physical therapy services Patient Signature:___________________________ Date:___________________ If patient is under 18 y/o, Parent/Guardian Name and Signature is required
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