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
* By selecting "I AGREE" below, you confirm the email address you entered above is yours and no other individual has access to your email account. This email address should match the email address where you received the link for this intake. *
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.
Please click to download and read our "consent to treat" policy and click an answer below if you agree or disagree to the policy as written here
Send me a copy of my responses.
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