Patient Information Form

Please fill out the form below. If you prefer a paper copy, print, fill out and bring to your first appointment this form.

Contact Information

Full Name
Address
Phone # 1
Phone # 2
Occupation
Date of Birth
Email    Join our newsletter
Referred to us by
Insurance company name
Insurance company address
Insurance company phone #
Policy holder name
Policy # (ID)
Group #

I hereby authorize payment of insurance benefits for service provided directly to New York Physical Therapist. I further authorize the release of medical information necessary to process claims for these services. Should New York Physical Therapist not be reimbursed in full by my insurance for any reason, I will pay the balance due when requested to do so.

Date    Signature (type your full name)

N.Y.S. LAW REQUIRES A PRESCRIPTION FOR PHYSICAL THERAPY TREATMENT AFTER THE FIRST VISIT.

PLEASE NOTE: THERE WILL BE A CHARGE FOR AN APPOINTMENT NOT CANCELLED 24 HOURS IN ADVANCE.

PLEASE INFORM YOUR THERAPIST ABOUT ANY DISCOMFORT DURING TREATMENT.

Pain History

Describe the purpose of your visit:

Describe any other problems or symptoms that accompany your pain:

How did your pain first start: (check all that apply)
Suddenly   / Gradually   / Lifting   / Fall   / Twisting   / Bending   / Pulling   / Injured at work
Sports   / Accident   / No Apparent cause   /   Other:

Describe specifically how and when your injury(ies) occurred:

What makes your pain worse? (check all that apply)
Exercising   / Sitting   / Standing   / Walking   / Bending   / Lying down   /   Other:

What makes your pain less? (circle all that apply)
Lying down   / Sitting   / Standing   / Medication   / Manipulation   /   Other:

If zero (0) is no pain and ten (10) is the worst pain imaginable, how would you rate your pain?

Is your pain:

Do you use a cane walker or wheel chair to help you around?

Past Pain Treatments

(TENS, nerve clock, physical therapy, medicine, acupuncture, counseling, biofeedback, surgery, epidural or trigger point injections)

Treatment: Did it help?

Do you have or did you have any of the following: (check all that apply)
Pace Maker   / High blood pressure   / Diabetes   / Stroke   / Seizures   / Cancer   / Metal
Other:

Where is your pain located?

Where does your pain radiate or travel to?

Please add any other important information that may clarify your situation:

Date    Signature (type your full name)

 

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