New Patient Information
Welcome to Plexus Physical Therapy. To help us assist you in your care, please complete the following information.
Name
(First Last)
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Date of Birth
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Gender
Address
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Phone Number
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Phone Type
Email Address
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Emergency Contact Name
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Emergency Contact Phone
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Emergency Contact Relation
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Favorite Music
(Artist, band or genre) :)
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Physician
The one who manages your condition of concern
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City of the Physician's Office
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Diagnosis
(What can we help you with?)
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Tells us a bit about what what is going on:
Anything you think is helpful: dates, MRI or X-ray, doctor's comments, and your experience.
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Please check any of the following that apply to you:
Pain level
Please check the current, best, and worst pain in the past 24 hours.
Medication
Please list the medication you are currently taking, to the best of your knowledge.
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How did you hear about us?
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