Physical Therapy Intake Form

Information you will need

• Do you have allergies?
• Do you have anxiety?
• Do you have arthritis?
• Do you have asthma?
• Do you have bladder or bowel problems?
• Do you have cancer?
• Do you have cardiac disease or conditions?
• Do you have a pacemaker or defibrillator?
• Do you have circulation problems?
• Are you currently pregnant?
• Do you have diabetes?
• Do you get dizziness or vertigo?
• Do you have any fractures?
• Do you have gastrointestinal problems?
• Do you have gallbladder or kidney problems?
• Do you suffer from headaches or migraines?
• Do you have hepatitis?
• Do you have high blood pressure?
• Do you have metal implants?
• Do you have numbness or tingling?
• Do you have Parkinson's?
• Do you get seizures?
• Do you have speech problems?
• Have you had a stroke?

…and 102 more fields in the PDF.

Completed by the client.

The form includes 1 signature line.