Client Intake Form
Please complete prior to any physical or occupational therapy evaluation (your first visit). The information you provide will help us better serve you!
Email address *
Please provide your name *
Your answer
What is your date of birth? *
MM
/
DD
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YYYY
Preferred or nickname
Your answer
Address *
Your answer
Preferred contact phone number *
Your answer
Preferred contact method *
Required
Referring provider (if applicable)
Your answer
Primary care provider (if applicable)
Your answer
Next physician appointment (if applicable)
MM
/
DD
/
YYYY
Other providers you are currently seeing (check all that apply):
Date of surgery (if applicable):
MM
/
DD
/
YYYY
Next appointment with surgeon (if applicable)
Your answer
Current restrictions according to MD
Your answer
Reason for attending therapy today: *
Your answer
Do you currently work? *
Where do you work (if applicable)?
Your answer
Is this injury work-related? *
Approximately how many hours in a day do you spend sitting? *
Approximately how many hours in a day do you spend standing? *
Approximately how many hours in a day do you spend bending/lifting/twisting? *
List all previous surgeries
Your answer
List any imaging (x-rays, MRIs, etc) related to this condition
Your answer
List any imaging (x-rays, MRIs, etc) related to this condition
Your answer
List any allergies
Your answer
List any allergies
Your answer
Please list all current medications (not needed if list was brought to clinic):
Your answer
How would you rate your current nutrition status? *
Poor - considerable sugar, complex carbs, fast food, or inadequate nutrition
Excellent - Three healthy meals per day with healthy snacks between, and adequate water intake
How much stress would you say you are currently experiencing? *
Hardly any
An extreme amount
Do you use tobacco? *
If you currently use tobacco, indicate how much and what type:
Your answer
Please use this space to describe any other concerns or issues you would like your therapist to be aware of today:
Your answer
What are your therapy or wellness goals? *
Your answer
How did you hear about us? *
Your answer
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This form was created inside of Fit & Function Therapy Solutions, PLLC.