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
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- best sports medicine doctors
- what does sports medicine involve
- sports medicine doctor near me
- sports medicine tucson
- sports medicine physician near me
- what do sports medicine doctors do
- sports medicine physician career
- what does a sports medicine physician do
- american sports and fitness association
- orthopedic surgery sports medicine salary
- andrews sports medicine birmingham
- andrews sports medicine gulf breeze