Physical Therapy Intake Form

  • (If YES, please STOP and talk to a receptionist at this time BEFORE Continuing)

  • Have you ever been told you have the following: (select all that apply) *
  • Please list any prescription or over-the-counter medications that you are currently taking.
  • Have you had any x-rays, sonograms, CT scans, or an MRI done recently? *
  • List occupation: