Physical Therapy Intake Form

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Please complete this initial intake for new patients prior to your visit. We will not be able to start your visit unless this form is completed.

At Home Therapy of Crystal Coast, LLC

Email *

* By selecting "I AGREE" below, you confirm the email address you entered above is yours and no other individual has access to your email account. * *

I AGREE

Welcome to At Home Therapy!

Full Name *

Injury description (brief summary) *

Red Flag Questions *

Random Fevers in prior 3 months

Bowel or Bladder changes in prior 3 months

Motor vehicle accidents or ED visits in prior 3 months

Fractures or new medications in prior 3 months

Falls in the prior 3 months

Any unrelenting night pain in the prior 3 months

None of the above

How has this injury impacted your daily activities? *

Please list all medications that you are currently taking. *

Click to download and read our "consent to treat" policy then check the check box to confirm that you have a copy and understand the consent form. https://drive.google.com/file/d/1S3D043OCSI3qKiB1ZxvXzgYNeqcUzeAe/view?usp=sharing * *

I have a copy and I give consent to treat.

Required

Send me a copy of my responses.

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