Patient Intake Form

If you are a new patient and would like to complete our intake form in advance, please download this PDF.  Patient Intake Form.

 

Online Patient Intake Form

Personal Information

Contact Information

Would you like to receive appointment reminders? *

Insurance Information

Patient Medical History

Are you on any other therapy services and/or Home Health? *
Do you currently have an open liability or worker's compensation claim for any medical condition? *
Do you have any medical/physical restrictions for activity? *
Do you have a pacemaker or any other implanted device? *
Are you pregnant? *
Do you have allergies? *

Medical Conditions

Please check all medical conditions that apply to you: *

Major Complaint

Was surgery performed? *
Was there a specific injury? *
Are you in pain? *
At worst pain *
Current pain *
At least pain *

Signature

By signing below, I attest that I have provided all relevant information about my current condition that would impact the construction, execution, and billing of a Physical Therapy plan of care.

Function First Physical Therapy

670 Albemarle Dr., Suite #1100 ~ Shreveport, LA 71106 & 2122 Airline Drive, Suite 200 ~ Bossier City, LA 71111

Call or Text (318) 828-1450 ~ contactus@functionfirstla.com

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