Physical Therapy Initial Patient Registration Form

Patient Information

• Full Name: _________________ Date: _________________
• Date of Birth: ______________ Gender: _______________
• Address: _________________________________________
• Phone: (Home) _____________ (Mobile) ______________
• Email: _________________________________________
• Emergency Contact: _____________ Phone: ___________
• Primary Care Physician: __________________________

Insurance Information

• Primary Insurance: _______________________________
• Policy Number: _________________________________
• Secondary Insurance: ____________________________
• Policy Number: _________________________________

Medical History

Current Symptoms

• Primary Complaint: ______________________________
• Date of Onset: _________________________________
• Pain Level (0-10): ______________________________
• Previous Treatment: ____________________________

Medical Conditions (Check all that apply): □ Diabetes □ Heart Disease □ High Blood Pressure □ Arthritis □ Osteoporosis □ Cancer □ Other: _______________________________________

Surgical History

• Previous Surgeries: _____________________________
• Dates: _______________________________________

Current Medications

Patient Consent

I certify that the above information is accurate to the best of my knowledge.

Signature: _________________ Date: _________________