Physical Therapy Intake Form
Please complete this initial intake for new patients prior to your visit. We will not be able to start your visit unless this form is completed.
At Home Therapy of Crystal Coast, LLC
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Welcome to At Home Therapy!
Injury description (brief summary)
Red Flag Questions
Random Fevers in prior 3 months
Bowel or Bladder changes in prior 3 months
Motor vehicle accidents or ED visits in prior 3 months
Fractures or new medications in prior 3 months
Falls in the prior 3 months
Any unrelenting night pain in the prior 3 months
None of the above
How has this injury impacted your daily activities?
Please list all medications that you are currently taking.
Click to download and read our "consent to treat" policy then check the check box to confirm that you have a copy and understand the consent form.
I have a copy and I give consent to treat.
Send me a copy of my responses.
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