New Patient Form for Physical Therapy

Eastside PT & Body Restoration

New Patient Information Sheet

Welcome to our practice!

Please help us serve you better by taking a few minutes to provide the following information.

Name:_______________________________________________________________________       Today's Date:________________________________

Last name                            First Name


Street Apt# City State Zip

Phone Number:  Cell (______)____________________          Home (______)____________________          Work (______)____________________

Date of Birth:__________________     Age:____________________     Gender:   M     F


Occupation:_______________________________________________   Employer:__________________________   Marital Status:   M   S   W   D


Emergency Contact:     Name:______________________________     Phone: (______)____________________


Primary Care Physician:____________________________________     Date of next visit: _________________

Specialist Physician: _______________________________________     Date of next visit: _________________


How did you hear about our practice? ____________________________________________________________

Did anyone refer you? __________  Name: __________________________________________________________


The following is very important in our evaluation process.

Please fill out these forms as specifically as possible to provide us with a clear picture of your 

present pain and functional status.

What is the primary complaint that brings you in today?             


Secondary complaint?

As a result, I am now having difficulty with:

Are you currently experiencing pain as a result of these symptoms?     Yes       No


When did your symptom(s) begin? Date: ____________________

Please rate the Intensity and Frequency of your pain with "0" being no pain, "5" being moderate pain, and "10" being unbearable pain.

Your Pain Intensity Rating: ______________________________ Your Pain Frequency Rating: ______________________________


More specifically, rate your pain using the At its worst ____________________

same "0" to "10" scale. At its best ____________________

At present ____________________

Night (sleeping) ____________________

At what time of day are your symptoms the worst? ________________________________________________________________

At what time of day are your symptoms the best?  _________________________________________________________________

What activities increase your pain?  _______________________________________________________________________________

What activities decrease your pain?  _______________________________________________________________________________

What other types of treatment have you had for this problem?

_____Massage _____Bodywork _____Physical Therapy _____Myofascial Release _____Chiropractic

_____Surgery _____Other Medical Treatment: (Please Describe) ________________________________________________


Check the box if you have had any of the following medical conditions?

__________ Diabetes __________ Varicose veins __________ Neurological problems

__________ Rheumatic fever __________ Circulatory problems __________ Stroke

__________ Heart Murmur __________ Lung disease __________ Broken bones (fracture)

__________ High blood pressure __________ Epilepsy/seizures __________ Kidney disease

__________ Heart disease/pacemaker __________ Malignancy __________ Liver disease

__________ Migraine headaches __________ Arthritis __________ Metal implants

__________ Osteoporosis __________ Pregnancy __________ Blackouts

__________ Weight change __________ Other: explain_______________________________________________

List past medical history and dates of occurrence. Include surgeries, accidents and other traumas.




List ALL medications which you are currently taking, the condition for which you are using them, the dose, and their effectiveness. (Include Supplements, herbal and homeopathic remedies).

Medication for treatment of  Dose/Amt. per day Effectiveness





Do you have any skin or medication allergies?    Yes __________  No __________

If so, which? ____________________________________________________________________________________________________________


Is there a chance you may be pregnant at this time?  Yes __________   No __________

Do you engage in regular exercise? Yes __________   No __________

What type and how often? __________________________________________________________________________________________________________________


are you able to exercise now? Yes __________   No __________


Do you have discomfort, shortness of breath, or pain with exercise?     Yes __________   No __________

Please describe ___________________________________________________________________________________

In general, your lifestyle is: 1 2 3 4 5

Active            Average                   Inactive

If sleep is a problem, answer these questions:

Do you have trouble falling asleep? Yes __________   No __________

Is your sleep restful? Yes __________   No __________

Do you find it difficult to lie down? Yes __________   No __________

Do you find it difficult to change positions in bed? Yes __________   No __________

How many times do you wake in the night?     _____________________________

How long before you fall back to sleep?   ___________________________________________

List all the TASK/ACTIVITIES that you have difficulty performing and your tolerance (minutes/hours) for each task/activity. If you are no longer able to perform an activity, your tolerance would be "0".


Task/Activity Tolerance (minutes/hours)

1.__________________________________________ 1. _________________________________________

2. _________________________________________ 2. _________________________________________

3. _________________________________________ 3. _________________________________________


List the activities that you would like to be able to do as a result of therapy.

Activity Duration/How Often By When

1. _____________________________________________ _______________________________ ____________________________

2. _____________________________________________ _______________________________ ____________________________

3. _____________________________________________ _______________________________ ____________________________


Other Goals? ____________________________________________________________________________________________________________


I understand that Eastside PT & Body Restoration, may use or disclose my personal health information for the purpose of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment.  


Photographs taken during initial evaluation, progress evaluation and discharge summary will be used for postural comparison purposes and as educational tools. By signing below you consent to the use of these photographs in a professional manner.


I do hereby agree and give my consent for Eastside PT & Body Restoration, to furnish care and treatment which is considered necessary and proper in the diagnosing or treatment of my physical conditions.


I understand that I retain the right to revoke this consent by notifying the practice in writing at any time.


I hereby certify that all the above information is true to the best of my knowledge.


Patient/Parent/Guardian Signature: ___________________________________________________   Date:________________________

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