Full Name
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First Name
Last Name
Email
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Phone
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Mailing Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
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Primary Care Provider Phone
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Emergency Contact Phone
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Primary Complaint/Reason for Seeking PT
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Please indicate the primary issues/injuries/desired outcomes which caused you to seek out physical therapy.
Is your reason for seeking PT related to an injury on the job, a motor vehicle accident, or litigation?
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Symptom Timeline
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When did you start experiencing symptoms? Or, when did you decide to come to physical therapy, and what prompted you to do it?
Pain/Symptom Description
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If you are experiencing pain/discomfort of any kind, what terms best describe it? Check all that apply.
Pain/Symptom Frequency
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If you are experiencing pain/discomfort of any kind, how often has it occurred on average in the last 2 weeks?
Pain/Symptom Severity
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Which option best describes your average experience in the last 2 weeks?
Have you ever had these same or very similar type of symptoms before?
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Have you been to PT before, for any reason?
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Are you currently being treated or have you been treated in the last year by any other physical therapist, occupational therapist, massage therapist, podiatrist, chiropractor, or other professional for these same symptoms/reasons?
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If yes, please provide a summary of the type of treatment you are/were receiving.
Have you ever been placed in a cast, splint, ace wrap, or sling for this injury?
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Have you had a cortisone injection for this injury or otherwise?
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Have you had a surgery related to these symptoms before?
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If yes, please describe the type of surgery and estimate of date(s).
Occupation/Role
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Are you currently working?
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Typical Exercise Routine/Frequency
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Please indicate any exercise, or generally any physical activities, which you do routinely. How often do you do them?
Hobbies/Other Activities
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Please indicate any other typical activities that you do with frequency.
Do you use/wear an assistive device of any kind? If so, how often? Please describe.
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This includes wearing braces, orthotics, prosthetics, using grab bars, etc.
Sleep Quality
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Select the answer that reflects your average experience.
Sleep Position
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Select all answers that are applicable.
Stress Levels
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Select the option that best represents your average experience over the last several months.
Are you currently taking any medications/supplements?
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If you are currently taking medications/supplements, please explain.
Please indicate specific type, what condition they are used for, and average frequency.
Do you have any allergies to latex?
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Do you have any of the following:
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Check all that apply.
If the answer is yes to any of the above, please briefly explain and provide dates of surgeries/events as able.
Within the past year, have you had any of the following tests?
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Check all that apply.
*We may request from your physician any reports indicated and/or other information that would be helpful in the course of your treatment, if necessary. This will be discussed with you, if applicable.
If the answer is yes to any of the above, please briefly explain.
Do you have or have you had any other medical conditions, surgeries, tests, treatments, or otherwise which you would like to disclose?
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If the answer is yes to the above, please briefly explain.
What are YOUR personal PT goals?
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Your PT will always create individualized rehab goals. But, what does a successful course of PT mean to you?
Do you have any specific requests that would make your PT experience as smooth as possible?
This may include physical assistance needs, larger text reading materials (adapted for those with visual impairment), requests for lower grade level reading materials (adapted for people with lower health/otherwise literacy), etc. If yes, please explain.
Electronic Signature (Consent for PT)
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I understand and acknowledge the following:
I authorize Lovely Bones LLC to release and request information to/from medical providers, if necessary, for the benefit of my physical therapy treatment and overall health. I authorize assignment of benefits directly to this practice.
The purpose of physical therapy is to treat disease, injury, and disability by careful examination, evaluation, diagnosis, prognosis, and intervention by use of rehabilitative procedures such as mobilization, massage, exercises, and physical agents to aid the patient in achieving their maximum potential within their capabilities and to accelerate convalescence and reduce the length of functional recovery. All procedures will be thoroughly explained to you before you are asked to perform them.
Response to physical therapy intervention varies from person to person; hence, it is not possible to accurately predict your response to a specific modality, procedure, or exercise protocol. Lovely Bones LLC does not guarantee what your reaction will be to a specific treatment, nor does it guarantee that the treatment will help resolve the condition that you are seeking treatment for. Furthermore, there is a possibility that the physical therapy treatment may result in aggravation of existing symptoms and may cause pain or injury. It is very important to communicate with your treating physical therapist throughout your treatment in order to ensure the most optimal outcomes which are possible given treatment response and circumstance.
It is your right to decline any part of your treatment at any time before or during treatment, should you feel any discomfort or pain or have other unresolved concerns. It is your right to ask your physical therapist about the treatment they have planned based on your individual history, physical therapy diagnosis, symptoms, and examination results. Consequently, it is your right to discuss the potential risks and benefits involved in your treatment.
All patients must recognize that they are responsible for the charges incurred for physical therapy. Lovely Bones LLC is a private pay practice and does not accept insurance at this time. It is expected that payment for each individual session be made at or before the scheduled appointment time. Practitioners of Lovely Bones LLC have the right to refuse or defer treatment if proper payment has not been made. If you choose to adjust your appointment frequency or duration, that is up to your discretion and must be discussed with your physical therapist; however, we ask that you make this request by giving us a minimum of 24-hours notice, prior to your upcoming scheduled appointment time. If you do not cancel or reschedule an appointment within this timeframe, you will be subject to a $50 fee for your missed physical therapy appointment. Please note that this charge must be paid on or before your next scheduled appointment. If you miss three (3) or more appointments without 24-hours notice, you may be discharged from physical therapy and your physician will be notified, if applicable to your case.
I have read this consent form and understand the risks involved in physical therapy and agree to fully cooperate and comply with the established plan of care.
Current Date
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