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Agape Physical Therapy

New Patient Intake Form

Do you have an appointment? *
Have you ever been a patient with Agape Physical Therapy? *
Please click here to fill out our appointment request form for current patients.
Please select one *
Patient Information
Diagnosis/Injury Description
Have you had surgery for the occurring problem? *
Have you had 2 or more falls in this past year or any fall with injury? *
Have you had any injections for your symptoms? *
Have you had any other PT/OT/SLP or Homecare in last 12 months? *
Are you under Chiropractic care?
Have you had any diagnostic testing for these symptoms?
Have you experienced any sudden weight loss? *
Have you been experiencing any recent fever or chills? *
Have you been experiencing any recent nausea or vomiting? *
Have you experienced any abdominal pains, gassiness, or belching? *
Does your pain change after or before eating? *
Have you had a hospitalization within the last 6 months for this issue? *
Have you ever had an Independent Medical Exam (IME)? *
Medical History
Please check all that apply
Medications List
Please list all medications, including all prescriptions, over the counter medications, herbals, minerals, vitamins, and dietary supplements
Employment Information
Are you currently working?
How many hours per week?
Please select one
Do you have any work restrictions due to this condition?
Please provide your personal insurance information if you would like as back up to your Motor Vehicle insurance.
Do you have secondary insurance?
Automatic Appointment Reminders
Complete this form and sign below to give Agape Physical Therapy your permission to provide automatic appointment reminder service by cellular text message or automated phone call.
Agape may send me messages to confirm my upcoming appointments via
I recognize that text messaging rates may apply
We cannot activate your text message appointment reminders without knowing your cellular carrier. If your carrier is not listed, we will be unable to activate text message alerts for you
HIPAA Acknowledgement of Receipt of Notice
I hereby acknowledge that I have been informed of the Agape Physical Therapy HIPAA Notice of Patient Information Privacy Practices. I give Agape Physical Therapy permission to leave voicemails regarding appointments and / or care at previously listed and below listed phone numbers. I give Agape Physical Therapy permission to discuss my information regarding Physical Therapy with the following people.