Intake Form
Please take the time to fill out this form so we can spend time treating instead of paperwork on your first visit!
Email address *
Name (Last, First) *
Your answer
How Old Are You? *
Your answer
Today's Date *
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Address (City, State, Zip) *
Your answer
Physician *
Your answer
Phone # *
Your answer
Date of Birth *
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Email *
Your answer
Occupation *
Your answer
Employer
Your answer
How did you hear about my practice? *
Your answer
Can I thank anyone specific for the referral?
Your answer
Please describe WHERE your pain is? *
Your answer
Rate Your Pain. 0 is no pain at all, 10 is take me to the emergency room pain. *
No pain at all
Take me to the hospital
What is the PRIMARY issue you are having today? *
Your answer
Do you have a secondary issue? If so, please describe. *
Your answer
What are you having difficulty with as a result of the above issues? *
Your answer
When did these symptoms begin? *
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What makes your symptoms BETTER? *
Your answer
What makes your symptoms WORSE? *
Your answer
Have you received any other treatments for this? *
Required
Have YOU ever been diagnosed with any of the following? *
Required
Is there a chance you are currently pregnant? *
How Many Children Do You Have? *
Your answer
Please Describe Your Birth Story(ies): *
Your answer
Please List any medications *
Your answer
Do you smoke? *
Are you currently exercising? *
Please list how often you are exercising and what type of exercise you are doing *
Your answer
Do you have problems sleeping? Explain *
Your answer
Allergies *
Your answer
Please List Your Goals for Physical Therapy: *
Your answer
Check any of the following that apply for your BLADDER: *
Required
How many times per day do you urinate? *
How many times do you urinate at night? *
How much water do you drink in one day? *
Your answer
What else do you drink everyday and how much? *
Your answer
Please check any of the following that apply to you: *
Required
Please Explain Anything Else You Would Like Dr. Kaylee to Know Prior to Your First Visit: *
Your answer
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