OCPT Client Info & Background
Let's Get Ready for Your First Visit!
Thank you for taking the time to fill out this short questionnaire.
Client's Full Legal Name
Date of Birth
Address (including unit, city, and zip code)
How did you hear about OCPT?
If you were referred by a Physician, please enter their name here
Do you have a prescription?
Is your physical therapy case a part of an on-going lien?
Yes (if yes, please provide front desk with additional information IE. case manager information and case #)
What is your primary insurance company? If none, please enter "self-pay."
Please enter your full insurance ID number. (Type NA if self-pay)
Reason for visit with OCPT:
Post Surgical Rehab
If "Post Surgical Rehab" tell us what surgery? If "Other" tell us more.
Describe your pain to us i.e. location of pain and type of pain (sharp, dull, numbness, shooting)
On what date did your current condition/complaint begin?
Level of pain you are experiencing for your current complaint
You should be in the hospital
What are your limitations because of your current complaint?
Activities of Daily Living
Lying on Back
What activities or movements aggravate your pain?
What activities or movements give you pain relief?
Indicate which of the following you have had, or have at the present. Check all that apply.
Heart (Surgery, Disease, Attack)
High/Low Blood Pressure
Artificial Joints (Knee, hip, etc)
A.I.D.S. or H.I.V. Positive
None of the above
Previous orthopedic surgeries? (type and year)
Other surgeries? (type and year)
Are you taking any pain medication? If yes, what they are and how often you are taking them.
Is there any other information you'd like for us to know?
Emergency Contact (Name, Relationship, and Phone Number)
Would you like to be sent e-mail or text reminders of your appointments?
Consent to treat: I consent to receive rehabilitation therapy treatment and any supplementary services that are deemed medically necessary or appropriate by my therapist and/or treating physician. However, I understand that the practice of rehabilitation therapy is not an exact discipline and I acknowledge that no guarantees have been made to me regarding treatment and/or the treatment results from the rehabilitation therapy.
Agree and I am over 18 y/o
Agree and I am under 18 y/o and will have my legal guardian with me during the first visit
Photo and Video Release: I hereby grant OCPT permission to use my likeness in a photograph or video in any and all of its publications, including website entries, without payment or any other consideration. I understand and agree that these materials will become the property of the OCPT and will not be returned.
I do not consent
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This form was created inside of Orange County Physical Therapy OCPT, Inc..