WEST
3899 W Front St Unit 3, Traverse City, MI 49684
(231) 944-6541
CENTRAL
722 Munson Ave, Traverse City, MI 49686
(231) 421-9300

Online New Patient Intake Form

The Superior Method
senior man in nursing home with doing physical

Online Form is not available for mobile devices.

Patient Intake Form

For your convenience you may print out the forms and bring them with you to your appointment or you may fill them out on line. If you choose to fill them out on line please remember to click submit and the forms will be sent directly to our clinic. Thank you.

Print Form

    Patient Intake Form


    MaleFemale

    SingleMarriedDivorceWidowed

    Referral Information


    YesNo

    YesNo

    Emergency Contact

    Insurance Information


    YesNo

    For Office Use Only

    Insurance VerifiedDeductibleCo-PayCo-Insurance



    Confidential Patient Information

    Current Condition


    0%25%50%75%100%

    X-RayMRICTEMG/NCVOther

    YesNo

    Personal Health History
    General Current Conditions

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

    AccidentSurgeryFallWhiplashBlow to Head
    Muscle SpasmsNumbness / TinglingRadiating PainRestricted MovementSpinal DisorderShoulder / Arm / Hand problemsHip / Leg / Foot problemsJaw / Mouth problems
    Head AchesMigrainesDepressionAnxietyDizzinessVision problemsNauseaSleep problems
    Asthma / Breathing problemsHigh Blood PressureConvulsions / EpilepsyHearburn / Acid RefluxDigestive problemsMenstrual problemsSinus problemsStress problems

    Diagnosed Condition

    Born with Bone / Joint DisorderDegenerative ArthritisRheumatoid ArthritisAnkylosing SpondylitisCompression FactureHeart Attack DisorderHistory of Stroke or AneurysmCancerDiabetesMultiple Sclerosis
    GoutLupusTuberculosisHepatitis B or HIV InfectionThyroid or Hormone DisorderOsteoporosis / OsteopeniaImmune Supression Treatment / Disorder from Chemotheraphy, Organ Transplant, drugs, etc.3+ months Steroid Medication or Intravenous drugs (past or present)

    Describe Your Habits


    GoodFairPoor

    Specific Body Pain

    Neck pain with difficult swallowingExtreme neck stiffness with pain or 'electric shocks' in arms or legs when moving neckNumbness or tingling of hands or feet or radiating painLeg pain with exerciseNumbness of inner thighsBack pain with urinary problemsSevere pain that interrupts sleepConstant pain that does not improve by changing positions or lying down

    Specific Current Conditions

    Poor balance when walking or standingBlurred or double vision, dizziness, nausea or faintness when neck is in certain positionsMemory loss after injuryRecent unexplained weight lossRecent progressive muscle weakness or shakingRecent or current fever over 102 °FLoss of bowel or bladder controlPregnant

    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 (To be filled up in the clinic)

    Personal Information/Activities Of Daily Living





    LeftRightBothNone

    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.





    I agree to the terms and conditions

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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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