New Patient Intake Form

Have you ever been a patient with Agape Physical Therapy? *

Yes No

Please click here to fill out our appointment request form for current patients.

Please select one *

Workers Compensation Claim Motor Vehicle Accident Other

Patient Information

Patient Name *

DOB *

SSN

Address *

City *

State *

Zip *

Primary Phone *

Cell Phone

Email Address *

Height *

Weight *

Primary Care Physician *

Referring Physician

Emergency Contact Name *

Emergency Contact Phone *

How did you hear about us? *

Diagnosis/Injury Description

What is your main complaint and in what area is it located? *

When did these symptoms begin? *

Have you had surgery for the occurring problem? *

Yes No

What activities make your symptoms worse? *

What activities make your symptoms better? *

Have you had 2 or more falls in this past year or any fall with injury? *

Yes No

Please rate your pain using a 0-10 scale (0=No Pain, 10=Hospitalization) *

Have you had any injections for your symptoms? *

Yes No

Have you had Physical Therapy for these symptoms before? *

Yes No

Have you had any diagnostic testing for these symptoms? *

X-Ray MRI CT Scan

Have you experienced any sudden weight loss? *

Yes No

Have you been experiencing any recent fever or chills? *

Yes No

Have you been experiencing any recent nausea or vomiting? *

Yes No

Have you experienced any abdominal pains, gassiness, or belching? *

Yes No

Does your pain change after or before eating? *

Yes No

Have you had a hospitalization within the last 6 months for this issue? *

Yes No

If so, when?

Have you ever had an Independent Medical Exam (IME)? *

Yes No

Is there any other information about your present health we should know about?

Medical History

Medications List

Please list all medications, including all prescriptions, over the counter medications, herbals, minerals, vitamins, and dietary supplements

Medication Name

Dosage

Frequency

Method of Administration

Medication Name

Dosage

Frequency

Method of Administration

Medication Name

Dosage

Frequency

Method of Administration

Medication Name

Dosage

Frequency

Method of Administration

Employment Information

Employer

Primary Work Duties

Are you currently working?

Yes No

How many hours per week?

Part Time Full Time

Please select one

Unemployed Disabled Student

Do you have any work restrictions due to this condition?

Light Duty Full Duty No Restrictions

Insurance

Insurance Company Name

Billing Address

City

State

Zip

Claim #

Contact Person/Case Manager

Case Manager Phone Number

Case Manager Fax Number

Insurance Company Name

Billing Address

City

State

Zip

Claim #

Contact Person/Case Manager

Case Manager Phone Number

Case Manager Fax Number

Please provide your personal insurance information if you would like as back up to your Motor Vehicle insurance.

Primary Insurance Company

Member ID #

Subscriber Name

Subscriber DOB

Relationship

Do you have secondary insurance?

Yes No

Secondary Insurance Company

Member ID #

Subscriber Name

Subscriber DOB

Relationship

Automatic Appointment Reminders

Complete this form and sign below to give Agape Physical Therapy your permission to provide automatic appointment reminder service by either email or cellular text message.

Agape may send me messages to confirm my upcoming appointments via

Email Text Message

I recognize that text messaging rates may apply

Email Address

Phone Number

Cellular Carrier

Please Specify Cellular Carrier

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.

Name

Phone Number

Relationship

I give Agape Physical Therapy permission to leave a message containing information pertinent to my Physical Therapy on my answering machine and/or voicemail if they are unable to reach me directly.

I have read and agree to Agapes Financial Policy and Consent to Treat

I hereby acknowledge that I have been informed of the Agape Physical Therapy HIPAA Notice of Patient Information Privacy Practices. *

[Commercial Insurance Patients] I understand that Agape Physical Therapy reserves the right to charge a $15 fee in the event that I do not arrive at my scheduled appointment time or I cancel my appointment with less than 24 hours notice. This fee does not apply if the appointment is rescheduled within the same Monday - Friday business week.

[Worker's Compensation / MVA Patients] I understand that I am responsible to attend appointments based on Doctors Referral and Case Manager authorization. If for any reason the patient does not abide by these guidelines, both parties will be notified.

To the best of my knowledge, the information I have given is complete and accurate. I hereby give consent to receive therapy services. *

Parent/Guardian Name

Relationship to Patient

Signature *

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