Welcome to Synergy Sports Medicine and Fitness



Synergy Sports Medicine and Fitness

New Patient/Client Intake Form

Name:________________________Home Ph______________work phone___________

Address_______________________________________Todays date:________________

City______________St_____Zip____________

Email_______________________________________

Date of birth________Age___M__F__Height______Weight____Occupation__________

Have you ever received Physical Therapy before? Yes__No__ Referred by____________

Current injury/pain:_______________________________________________________

Date of onset:__________________________________

R vs L handed:___________________

How would you describe your symptoms: (circle all that apply) ache, sharp, dull, throbbing, referring, radiating, pins/needles, numb

What aggravates symptoms:_________________________________________________

What relieves symptoms:___________________________________________________

Pain min_______ Pain max_______ Pain now____________(0-10 with 10 maximum)

Please Check if you have any of these conditions at the present time:

__High stress __Disc problems __arthritis __heart problems

__recurring headaches __muscle spasms __Diabetes __shortness of breathe

__tight neck __cold arms/legs __skin cancer __high blood pressure

__grating in neck __cold legs/feet __other cancer __low blood pressure

__neck pain __tight shoulders __kidney disease __skin problems

__head feels heavy __numbness/tingling __allergies __bruise easily

__fatigue __pain arms/hands __abdominal pain __varicose veins

__dizziness __pain in legs/feet __digestive prob __blood clots

__fainting __low back/hip pain __constipation __wear contact

__loss of balance __knee/ankle pain __edema _wear dentures/night splint

Please list any other medical conditions:_______________________________________

Please list any prescribed medications(including supplements, herbs, etc)_____________

_______________________________________________________________________

Please list and date all prior surgeries:_________________________________________

________________________________________________________________________

Please list and date all injuries/accidents/broken bones:_________________________________________________________________________________________________________________________________________

________________________________________________________________________

Please list and date diagnostic tests:__________________________________________

Please describe exercise routine:_____________________________________________

_______________________________________________________________________

Your goals with activity/sport/competition

Please read and sign the following: Physical Therapy and wellness is intended for the relief of neuromuscular, skeletal pain, muscle tension, stress reduction, and promotion of healing, strength, stability, optimal health and function. It is the clients responsibility to provide pertinent health information and to inform the therapist of any changes. By signing below I consent to photos, videos and social media use for professional use only by Synergy Sports Medicine and Fitness.

I the undersigned, consent to treatments and services deemed necessary by my physical therapist/athletic trainer. It is this clinics sincere intent to educate me on every process, from treatment to discharge. Therefore, if ‘hands-on” manual or exercise techniques that are being used to retrain, recruit and restore postural alignment are not understood, it is my responsibility to obtain a clearer understanding of what the therapist’s objectives and outcomes are, and how he/she is trying to achieve them.

This consent shall be ongoing for a period not to exceed one year.

I also understand that payment is due at time of treatment, unless other arrangements are made. To prevent being charged 50.00, please give 24 hrs. notice of cancellation

I __________________________________________(print) have read this form and fully understand and accept its terms and conditions.

(signature)

Patient (or Person Authorized to consent for Patient/Relationship) date/time

Reason patient was unable to consent

Witness signature

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