Physical Therapy Intake Form – Fill Out and Use This PDF

The Physical Therapy Intake Form serves as the initial step in crafting a tailored physical therapy plan, encompassing detailed medical history, symptom description, and current health status. This form is meticulously designed to gather comprehensive information necessary for therapeutic consideration, including medical conditions, pain levels, and daily activities affected by physical ailments. To ensure the best course of treatment is determined, individuals are encouraged to accurately fill out this form by clicking the button below.

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Physical Therapy Intake Form PDF Details

The journey to recovery through physical therapy begins with a comprehensive intake process, facilitated by a detailed Physical Therapy Intake Form. Before any treatment plan can be devised, a physical therapist needs to understand a patient’s medical history, the genesis of their symptoms, and the impact of these symptoms on their daily life. This form, approved and mandated by the Office of The Surgeon General, serves as a fundamental tool in collecting this vital information. It encompasses various sections that inquire about medical conditions, symptom onset, prior injuries or surgeries, current medications, and any changes in general health. Patients are also asked to specify any discomforts such as numbness, tingling, or difficulty sleeping due to pain. Furthermore, the form delves into lifestyle habits that could affect treatment, including tobacco use and dietary concerns. Notably, the form is attentive to the emotional wellbeing of the patient, probing into feelings of depression or hopelessness, thus adopting a holistic approach to patient care. The Neck Disability Index portion of the form allows patients to express how neck pain affects their ability to perform daily tasks, offering a quantitative measure of the pain's impact on their lives. This comprehensive intake strategy not only aids therapists in crafting personalized treatment plans but also signifies the beginning of a patient's path to recovery.

Question	Answer
Form Name	Physical Therapy Intake Form
Form Length	3 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	45 sec
Other names	printable physical therapy forms, da mceuh medical online, master mceuh 370 latest, da mceuh medical

Form Preview Example

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA

For use of this form, see AR 40-66; the proponent agency is the Office of The Surgeon General

REPORT TITLE Physical Therapy Medical History Intake Form Neck Pain

OTSG APPROVED (Date)

MOS/Occupation:

Medical History:

Self

│

Family

Duty Station/Unit:

Cancer?

Yes

│

Yes

Diabetes?

Yes

│

Yes

When did symptoms start (date):

High Blood Pressure?

Yes

│

Yes

Symptoms related to deployment? □Yes-Combat □Yes-NonCombat □No

Heart Disease?

Yes

│

Yes

Osteoporosis?

Yes

│

Yes

Have you had these symptoms before? □Yes

□No

Osteoarthritis?

Yes

│

Yes

How did symptoms start?

Rheumatoid arthritis?

Yes

│

Yes

Neurologic dz (MS, Parkinsons)?

Yes

│

Yes

Symptoms are?

□Constant

□Come/Go

□Only with Activity

Ulcers / GERD / Acid Reflux?

Yes

│

Yes

Symptoms are?

□Getting worse

□Not Changing

□Getting Better

Kidney / Liver Disease?

Yes

│

Yes

Prior Surgeries:

Yes

│

List any medications or dietary supplements your are taking:

Other:

In the past 3 months have you had or do you experience:

□None

Change in your general health?

Yes

Fever / chills / sweats?

Yes

List any drug or latex allergies you are aware of:

□None

Unexplained weight change (>10lbs)?

Yes

Numbness or tingling?

Yes

List Assistive Devices you use (crutches, braces, shoe inserts):

Bowel / bladder incontinence?

Yes

□None

Difficulty sleeping due to pain?

Yes

Unexplained Falls/Decreased balance?

Yes

Are you in the Personal Reliability Program (PRP)?

□Yes

□No

Are you currently/Do you have:

Have you completed advanced medical directives?

□Yes

□No

Pregnant / Potentially Pregnant / Nursing?

Yes

Often bothered by feeling down, depressed, or hopeless?

Yes

(aka: “living will”)

Information is available at front desk.

Often bothered by little interest or pleasure in doing things? Yes

Do you have difficulties with? (check all that apply)

Under physical / emotional abuse?

Yes

□Communication

□Vision

□None

Dietary or Nutritional Concerns?

Yes

□Speech

□Hearing

□Other:

Do you use tobacco products?

Yes

Mark an “X” on the lines below that best describes your response.

Indicate the location and

1. Which activity causes you the most pain / most trouble performing?

type of pain on the chart:

___________________________________________

Function: Rate your ability to perform the ABOVE activity.

Key:

Ache/Dull: ^ ^ ^ ^

_________________________________________________________

Sharp/Stabbing: x x x x

Numb / Tingling: o o o o

Unable to Perform

No restrictions

2. Pain at WORST: Rate your highest pain level in past 72 hrs.

Pins & Needles: · · · ·

Burning: = = = =

_________________________________________________________

Throbbing: / / / /

Other Pain: - - - -

No pain

Worst pain

Imaginable

3. Pain at BEST: Rate you lowest pain level in past 72 hrs.

Therapist Notes:

_________________________________________________________

No pain

Worst pain

Imaginable

4.Impact: How distressing is this condition to you?

_________________________________________________________

0	1	2	3	4	5	6	7	8	9	10
No problem									Devastating

PATIENT SIGNATURE / PREPARED BY:

DATE

DEPARTMENT/SERVICE/CLINIC

LRMC Physical Therapy

APO AE 09180 486-8263

PATIENTS IDENTIFICATION (For typed or written entries give: Name-last, first, middle; grade; rank; hospital or medical facility)

HISTORY/PHYSICAL

FLOW CHART

NAME (Last, First MI):
FMP / SSN (Sponsor):	/
GRADE or RANK:	DOB:
	(Patients, dd-mmm-yyyy)

OTHER/EXAMINATION

OR EXAMINATION

DIAGNOSTIC STUDIES

TREATMENT

OTHER (Specify)

DA	FORM	4700	MCEUH OP 370-R, APR 96(Rev)
	1 MAY 78		DA 4700 Master Rx Form, Updated 13-May-11

NECK DISABILITY INDEX1

Section 1: To be completed by patient	_______AD	______Non-Active Duty
Name:______________________________	Age:_______	Date:__________________
Occupation:_________________________	Number of days of neck pain:_____________(this episode)

Section 2: To be completed by patient

This questionnaire has been designed to give your therapist information as to how your neck pain has affected your ability to manage in every day life. Please answer every question by placing a mark on the line that best describes your condition today. We realize you may feel that two of the statements may describe your condition, but please mark only the line which most closely describes your current condition.

Pain Intensity

_____I have no pain at the moment.

_____The pain is very mild at the moment.

_____The pain is moderate at the moment.

_____The pain is fairly severe at the moment.

_____The pain is very severe at the moment.

_____The pain is the worst imaginable at the moment.

Personal Care (Washing, Dressing, etc.)

_____I do not have to change the way I wash and dress myself to avoid pain.

_____I do not normally change the way I wash or dress myself even though it causes some pain.

_____Washing and dressing increases my pain, but I can do it without changing my way of doing it.

_____Washing and dressing increases my pain, and I find it necessary to change the way I do it.

_____Because of my pain I am partially unable to wash and dress without help.

_____Because of my pain I am completely unable to wash or dress without help.

Lifting

_____I can lift heavy weights without increased pain.

_____I can lift heavy weights but it causes increased pain

_____Pain prevents me from lifting heavy weights off of the floor, but I can manage if they are conveniently

positioned (ex. on a table, etc.).

_____Pain prevents me from lifting heavy weights off of the floor, but I can manage light to medium weights

if they are conveniently positioned.

_____I can lift only very light weights.

_____I can not lift or carry anything at all.

Reading

_____I can read as much as I want to with no pain in my neck.

_____I can read as much as I want to with slight pain in my neck.

_____I can read as much as I want with moderate pain in my neck.

_____I can’t read as much as I want because of moderate pain in my neck.

_____I can hardly read at all because of severe pain in my neck.

_____I cannot read at all.

Headache

_____I have no headache at all.

_____I have slight headaches which come infrequently.

_____I have moderate headaches which come infrequently.

_____I have moderate headaches which come frequently.

_____I have severe headaches which come frequently.

_____I have headaches almost all the time.

(Don’t forget to fill out the back side)

NECK DISABILITY INDEX, p. 2

Section 2 (con’t): To be completed by patient

Concentration

_____I can concentrate fully when I want to with no difficulty.

_____I can concentrate fully when I want to with slight difficulty.

_____I have a fair degree of difficulty in concentrating when I want to.

_____I have a lot of difficulty in concentrating when I want to.

_____I have a great deal of difficulty in concentrating when I want to.

_____I cannot concentrate at all.

Work

_____I can do as much as I want to.

_____I can only do my usual work but no more.

_____I can do most of my usual work, but no more.

_____I cannot do my usual work.

_____I can hardly do any work at all.

_____I can’t do any work at all.

Driving

_____I can drive my car without any neck pain.

_____I can drive my car as long as I want with slight pain in my neck.

_____I can drive my car as long as I want with moderate pain in my neck.

_____I can’t drive my car as long as I want because of moderate pain in my neck.

_____I can hardly drive at all because of severe pain in my neck.

_____I can’t drive my car at all.

Sleeping

_____I have no trouble sleeping.

_____My sleep is slightly disturbed (less than 1 hour sleep loss).

_____My sleep is mildly disturbed (1-2 hour sleep loss).

_____My sleep is moderately disturbed (2-3 hours sleep loss).

_____My sleep is greatly disturbed (3-5 hours sleep loss).

_____My sleep is completely disturbed (5-7 hours sleep loss).

Recreation

_____I am able to engage in all my recreational activities with no neck pain at all.

_____I am able to engage in all my recreational activities with some pain in my neck.

_____I am able to engage in most but not all of my usual recreational activities because of pain in my neck.

_____I am able to engage in a few of my usual recreational activities because of pain in my neck.

_____I can hardly do any recreational activities because of pain in my neck.

____ I can’t do any recreational activities at all.

Section 3: To be completed by physical therapist/provider
SCORE:________out of 50 (SEM 5, MDC 7)	Initial	F/U ___ weeks		Discharge
Number of treatment sessions:________________	Gender:	Male	Female
Diagnosis/ICD-9 Code:_______________________

1Adapted from Vernon H, Mior S. The Neck Disability Indes: A Study of Reliability and Validitiy. Journal of Manipulative and Physiological Therapeutics 1991; 14(7): 409-415.

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Ways to complete editable physical therapy intake forms stage 1

2. After this section is completed, go to type in the relevant details in these - Do you have difficulties with, None Other, Which activity causes you the, Function Rate your ability to, No restrictions, Pain at WORST Rate your highest, No pain Worst pain Imaginable, Pain at BEST Rate you lowest pain, No pain Worst pain Imaginable, Are you currentlyDo you have Yes, No No No No No No, Indicate the location and type of, Key AcheDull SharpStabbing x x, Therapist Notes, and Impact How distressing is this.

editable physical therapy intake forms conclusion process shown (step 2)

3. In this particular part, check out PATIENTS IDENTIFICATION For typed, NAME Last First MI, FMP SSN Sponsor, GRADE or RANK, DA FORM, MAY, DOB Patients ddmmmyyyy, OTHEREXAMINATION, OTHER Specify, OR EXAMINATION, DIAGNOSTIC STUDIES, TREATMENT, and MCEUH OP R APR Rev DA Master Rx. These should be filled out with utmost focus on detail.

Filling in part 3 in editable physical therapy intake forms

4. Filling in NECK DISABILITY INDEX, Section To be completed by, Name Age Date, Occupation Number of days of neck, Section To be completed by patient, I have no pain at the moment The, I do not have to change the way I, and This questionnaire has been is key in the fourth form section - make sure to don't rush and be mindful with every blank!

editable physical therapy intake forms writing process clarified (part 4)

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How to prepare editable physical therapy intake forms step 5

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Physical Therapy Intake Form – Fill Out and Use This PDF

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