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Online New Patient Intake Form

The Superior Method
senior man in nursing home with doing physical

PATIENT INTAKE FORM

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Male
Female
Single
Divorced
Married
Widowed

REFERRAL INFORMATION

Do you give us permission to give information to your Primary Care Physician?
Yes
No
Are you currently receiving services from a home health Agency?
Yes
No
How did you hear about Superior Physical Therapy?

INSURANCE INFORMATION

Yes
No

EMERGENCY CONTACT

For Office Use Only
Details

CONFIDENTIAL PATIENT INFORMATION

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CURRENT CONDITION

Briefly describe why you are here?
What caused it?
What makes it better?
What makes it worse?
What percentage of day does it bother you?
What activities are limited by it?
List other health professionals seen:
What test have had for it
Where?
Have you had 2 or more falls in the past year or fall with injury in the past year?

PERSONAL HEALTH HISTORY

GENERAL HEALTH CONDITIONS

(Please read all and check all that apply to you)
Recent

DIAGNOSED CONDITIONS

DESCRIBE YOUR HABITS

(Amount per day)
(Amount per day)
(Hours per week)
Other Conditions

SPECIFIC PAIN IN THE BODY

SPECIFIC CURRENT CONDITIONS

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PAIN RATING

Pain Level 0
Level 0 No hurt / No Pain
Pain Level 2
Level 2 Hurts Little Bit / Mild Pain Annoying
Pain is present but does not limit activity
Pain Level 4
Level 4 Hurts Little More / Nagging Pain
Can do most activities with rest periods
Pain Level 6
Level 6 Hurts Even More / Miserable Distressing
Unable to do some activities because of pain
Pain Level 8
Level 8 Hurts Whole Lot / Intense, Dreadful Horrible
Unable to do most activities because of pain
Pain Level 10
Level 10 Hurts Worse / Worst Pain Unbearable
Unable to do any activities because of pain
Rate your pain at its...
Least:
Most:
Average:
0
1
2
3
4
5
6
7
8
9
10
Pain Drawing

PERSONAL INFORMATION/ACTIVITIES OF DAILY LIVING

Home
Stairs: Maximum # of stairs in your home
When going up the stairs, are handrails on the
Lives (with)
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CONSENT TO EVALUATE AND TREAT

I hereby request and consent to the performance of various modes of physical therapy on me (or the patient named below, for who I am legally responsible) by Superior Physical Therapy and/or other licensed physical therapists working at the clinic. I further acknowledge that no guarantees or assurances have been made to me concerning the results intended from the treatments. I intend this consent form to cover the entire course of treatment of my present condition and for any future condition(s) for which I seek treatment. I understand that I may refuse treatment at any time and that I am responsible for my healthcare choices.

OUR PRIVACY POLICY

The office of Superior Physical Therapy is committed to upholding the security and confidentiality of personal information that you provide to us. We take responsibility of safeguarding your information very seriously. We do not share or sell patient information with anyone outside our office without your written consent. This policy covers information including personal, financial, or health information about a consumer or customer relationship.

I have been given a copy of the privacy policy of Superior Physical Therapy. I hereby authorize that my records of evaluation and treatment with the office of Superior Physical Therapy may be forwarded to referring physicians, specialists, or therapists, who are also involved in my healthcare. Your insurance claims will be transmitted through an electronic clearing house, in accordance with HIPPA regulations.

By agreeing below, I have read, or have had read to me, the above consent to evaluation and treatment statement, that I am aware of the privacy policy, and that I certify that my medical information above is correct to the best of my knowledge.

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Superior Physical Therapy is all about your priorities, professional service, a satisfying experience, best value, and your success. We want you to feel at ease when you come to visit us and to feel great about yourself when you leave.
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Contact Information
Office Hours: 
7am - 7pm Monday to Friday
Superior Physical Therapy (West) 
3899 West Front St., 
Traverse City, MI 49684
Superior Physical Therapy & Spine Center (Central) 
722 Munson Ave, Traverse City, MI 49686
© Copyright 2022 Superior Physical Therapy All Rights Reserved.
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