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About
Overview
Physical Therapy
Insurance
Facility
Patients
Performance
Return to Sport
Services
Overview
Soft Tissue Massage, Myofascial Release, & Instrument Assisted – Soft Tissue Massage (IA-STM)
Active Isolated & PNF Stretching
Trigger Point Release and Neuromuscular Techniques
Joint mobilization and Spinal Manipulations
Selective Functional Movement Assessment and Functional Movement Screen
Cupping & Dry Needling
Injury Prevention / Return to Sport
Staff
Testimonials
Contact & Locations
Forms
Appointment Request
About
Overview
Physical Therapy
Insurance
Facility
Patients
Performance
Return to Sport
Services
Overview
Soft Tissue Massage, Myofascial Release, & Instrument Assisted – Soft Tissue Massage (IA-STM)
Active Isolated & PNF Stretching
Trigger Point Release and Neuromuscular Techniques
Joint mobilization and Spinal Manipulations
Selective Functional Movement Assessment and Functional Movement Screen
Cupping & Dry Needling
Injury Prevention / Return to Sport
Staff
Testimonials
Contact & Locations
Forms
Appointment Request
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Athletic Evolution Physical Therapy Forms
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Physical Therapy Intake Form
Physical Therapy Intake Form
Physical Therapy Intake Form
Name
(Required)
DOB
(Required)
MM slash DD slash YYYY
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
Cell Phone
(Required)
Email
(Required)
Occupation
Employer
Work Address
Work City
Work State
Work Zip
Work Phone
Referring MD
Emergency Contact
(Required)
Relation
(Required)
Phone
(Required)
Insurance Company
Policy Number
Subscriber's Name
Subscriber's DOB
MM slash DD slash YYYY
Was injury due to an automobile or workers compensation accident? If yes, furnish the following:
(Required)
Yes
No
Date of Injury
MM slash DD slash YYYY
File Claim Number
Insurance Company
Insurance Company Address
Claim Adjuster Name
Phone
Past Medical History
Past Surgical History
Chief Complaint
(Required)
Mechanism of Injury
Imaging (MRI/X-ray/CT) and Date(s)
Pain (Rated 0 to 10)
Current
Worst
Best
Type of Pain
Dull/Ache
Stabbing
Sharp
Burning
Numbness
Radiating
Based on the locations outlined in the body diagram below, select the areas you are having pain, numbness, tingling
Issue areas
1. Neck
2. Shoulder (front)
3. Shoulder (back)
4. Elbow
5. Thoracic Spine
6. Hip (front)
7. Hip (back)
8. Lumbar Spine
9. Hand/Wrist
10. Thigh
11. Knee
12. Calf
13. Foot/Ankle
What makes it better?
Rest
Ice
Compression
Elevation
Heat
What makes it worse?
Mechanical Symptoms
Clicking
Catching
Popping
Locking
Grinding
Past Treatment/Interventions
Client Goals
Upload a copy of your insurance card
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Max. file size: 50 MB.
(Please include a copy of the front and back)
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Email
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