Name
*
First Name
Last Name
Age
*
Date
*
MM
DD
YYYY
Primary diagnosis:
*
Reason for seeking physical therapy at this time:
*
When and how did the symptoms begin?
*
Goals for physical therapy:
*
Goals for daily living:
*
Occupation (if unemployed, state "None"):
*
How would you rate your average quality of sleep?
*
Excellent
Good
Okay
Poor
How would you rate your overall nutrition?
*
Excellent
Good
Okay
Poor
How would you rate your overall hydration?
*
Excellent
Good
Okay
Poor
What is the name of your primary care physician?
*
How did you hear about Engaging Physical Therapy, LLC?
*
Have you experienced any of the following (select all that apply)? If no, select "no."
*
Have you ever been diagnosed with any of the following (select all that apply)? If no, select "no."
*
Do you have any heart conditions (select all that apply)? If no, select "no."
*
If other, please list:
Do you have any lung conditions (select all that apply)? If no, select "no."
*
If other, please list:
Do you have any joint conditions (select all that apply)? If no, select "no."
*
If other, please list:
Do you have any neurological conditions (select all that apply)? If no, select "no."
*
If other, please list:
Are you currently pregnant?
*
Yes
No
Any other health conditions and approximate dates of diagnosis? If none, state "None."
*
Any upcoming surgeries and approximate dates of surgery? If none, state "None."
*
What is your preferred email address?
*
What is your preferred telephone number?
*
(###)
###
####
What is your preferred method of contact (text, email, or phonecall)?
*
Thank you for submitting the Patient Information and Past Medical History form for Engaging Physical Therapy, LLC. We will review your information and get back to you via your preferred method of contact.
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