Patient Intake Form-Kirk Integrative PT

Patient Intake Form

This is the patient intake form for Kirk Integrative Physical Therapy. Before your first appointment with us, please complete and electronically sign this form and click Submit at the bottom when finished!

Legal Name

Date of Birth

Chosen Name

Current Date

Pronouns

Gender (check all that apply)

Assigned female at birth

Assigned male at birth

Cisgender

Genderfluid

Genderqueer

Intersex

Non-binary

Transgender man

Transgender woman

Prefer not to say

None of these apply to me

Address

Age

Occupation

Preferred Phone

Emergency Contact

Emergency Contact Phone

How did you hear about us?

Referring Provider

Referring Provider City

Referring Provider Phone

Do you want your treatment notes sent to this provider?

Yes

Is there someone else that you would like us to send this information to?

Additional Provider City

Additional Provider Phone

Diagnosis / Complaint

1000

List past surgeries and their dates

1000

List past and current conditions, diseases, injuries and infections and their dates:

1000

List current medications and supplements:

1000

List any foreign objects in your body (mesh, screws, plates, rods, stents, IUD, joint replacements, pacemakers):

1000

List any allergies:

1000

Are you currently pregnant?

Yes

Date and results of last pelvic / prostate exam:

Date and results of last mammogram:

Date and results of last DEXA scan / bone density test:

Date and results of any other recent tests:

1000

Activity level / work / hobbies:

1000

Severity of condition for which you're seeking physical therapy:

0 - No problems

10 - Unbearable

Your goal from physical therapy:

1000

Patient/Guardian Signature:

I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document.