Physical Therapy Intake Form

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CoreFitness

Your name *

Your email address *

Your phone number *

Your home address *

What is your primary goal(s) for working with a physical therapist? *

Have you worked with a physical therapist in the last 3 months? *

Yes

Do you have any of the following medical conditions ?(check all that apply) *

Stroke

Spinal Cord Injury

Traumatic Brain Injury

Heart Condition

Joint Replacement

Other injury

Parkinson's Disease

Multiple Sclerosis

Other:

Required

Please provide details to above response *

Do you require assistance for daily activities? *

Yes

Sometimes

Please provide details for above response *

How can I assist you in achieving your goals? (check all that apply) *

Design an appropriate exercise program that I can do on my own

Design and assist me with an exercise program

Provide hands on assistance for exercise, transfers or walking

Train my family members so they can assist me with daily activities

Other:

Required

Is there anything else you would like me to know that is important to helping you achieve your fitness/wellness/mobility goals? *

How would you like to submit payment for sessions? *

Cash

Check

Credit Card

Venmo

PayPal

Zelle

Required

Submit

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