Client Intake Form

Last Name, First Name *

Phone Number *

If you have had pain or discomfort, what would you rate the highest you have had in the past week? *

No pain/discomfort at all

0

1

2

3

4

5

6

7

8

9

10

Worst pain/discomfort need to go to the hospital

If you have pain or discomfort what few words would you use to describe it.

Do you have past medical history that may be important to consider during Physical Therapy? *

Yes

No

If the answer to the last question was yes describe the medical history.

List three things that you would like to be able to get back to doing more comfortably.