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Intake Form- SPARK Physical Therapy
Please complete this initial intake prior to your visit. We will not be able to start your visit unless your form is completed.
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Email
*
Your email
* By selecting "I AGREE" below, you confirm the email address you entered is yours and no other individual has access to your email account. This email address should match the email address where you received the link for this intake.
*
I agree
Required
Welcome to SPARK Physical Therapy!
Please watch our welcome video for an explanation of the process to get started with your first PT visit
Full name
*
Your answer
Home address (including town and zip code)
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Preferred method(s) of contact
Text
E-mail
Phone call
Injury description (brief summary)
*
Your answer
On a scale of 0-10, with 0 being no pain at all and 10 being the worst pain imaginable, how would you rate your pain AT WORST (within the past week)
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10
On a scale of 0-10, with 0 being no pain at all and 10 being the worst pain imaginable, how would you rate your pain AT BEST (within the past week)
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10
How has this injury impacted your daily activities?
*
Your answer
Do you have any significant past medical history/ chronic health issues?
Your answer
Please list all medications you are currently taking
Your answer
What injuries/ surgeries have you had in the past?
Your answer
What do you hope to get out of this visit?
*
Your answer
Please click
https://sparkyourtraining.com/consent
to read our "consent to treat" policy and click an answer below if you agree or disagree to the policy as written here (reply to this email if you would like a pdf copy of this consent form)
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I agree
I disagree
Required
Send me a copy of my responses.
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