Get Physical Therapy Screening Form

Completing the Physical Therapy Screening Form online is a crucial step in ensuring you receive comprehensive evaluation and care. This guide will walk you through each section of the form, providing clear instructions to facilitate your submission.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your full name and date of birth (age) in the designated fields.
3. Provide a phone number where you can be reached, ideally your work or daytime contact number.
4. Fill in your occupation to give the healthcare provider context about your daily physical activities.
5. List your leisure activities to inform the therapist about your lifestyle and interests.
6. Input your height, weight, and current blood pressure to help in understanding your physical health status.
7. State the name of the doctor who referred you, along with the date and type of any relevant injury or surgery.
8. Explain how the injury occurred, including details about the activity or location.
9. List your main reasons or goals for pursuing physical therapy, prioritizing them in order of importance.
10. Indicate if you are currently or have recently seen other healthcare professionals, circling and describing their involvement.
11. Review the conditions you have been diagnosed with, circling and providing details as necessary.
12. Document any family history of medical conditions as prompted.
13. Indicate if you have been in physical therapy this year, including the location and number of visits.
14. List any previous surgeries, injuries, and treatments used, providing approximate dates and details.
15. Report on any imaging studies you have undergone, noting what type they were and the reason for the tests.
16. Answer whether you experience urinary or bowel leakage.
17. Detail any prescription medications or supplements you are currently taking, including dosages.
18. Circle any over-the-counter medications you have taken in the last week.
19. State the amount of caffeinated beverages you consume daily and your tobacco use.
20. Finally, indicate how you found out about Mt. Stuart Physical Therapy.
21. After completing all fields, ensure to review your entries for accuracy before submitting the form.

Start completing your Physical Therapy Screening Form online today to ensure effective care.