Get Initial Patient Intake Form

Filling out the Initial Patient Intake Form online is an essential step in ensuring that your physical therapy provider has all necessary information to deliver personalized care. This guide will walk you through each section of the form, allowing for a smooth and efficient submission process.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to access the Initial Patient Intake Form and open it in your preferred online editor.
2. Begin filling out your personal information. This includes your name, social security number, address, phone numbers, birth date, email, and gender. Ensure all details are correct to prevent any issues with your therapy services.
3. Indicate your marital status by selecting the appropriate option. Provide details about your employer and occupation, including their address.
4. List information for your emergency contact, including their name and phone number. If there is another person financially responsible for the bill, provide their details as well.
5. Outline your medical insurance coverage, including the primary and any secondary insurance information. Make sure to input the policy holder's name and date of birth for each insurance provider.
6. For those under workers’ compensation, fill in the insurance details, case manager's contact, and the date of injury if applicable.
7. Complete your health history. Provide your height, weight, blood pressure, chief complaints, medications, past surgeries, and any imaging history.
8. Answer the health history questions, circling yes or no for any applicable conditions, and provide any additional relevant information.
9. Respond to questions regarding smoking habits, exercise regularity, previous physical therapy experiences, and therapy goals.
10. If you are a Medicare patient, indicate if you are receiving home health services.
11. Sign and date the form to attest that the medical history provided is accurate and complete. This section may also require the signature of a therapist.
12. Review the payment policies, initial the acknowledgment of understanding these terms, and provide your signature for the terms of agreement.
13. Finally, you can fill out the patient authorization for disclosure, indicating who can receive information regarding your treatment.
14. Once completed, ensure to save any changes made to the document. You can download, print, or share the form as necessary.

Complete your Initial Patient Intake Form online today to ensure all your information is accurately recorded for your upcoming therapy sessions.