Physical Therapy Mobility Intake Form

Physical therapy mobility intake form with sections for patient history, current mobility issues, and pain assessment

I. Client Information

First Name

Last Name


Date of Birth

Gender

Contact Information

Phone Number

Email Address

Street Address

City/Suburb

State/Province

Postal/Zip Code

Emergency Contact

Full Name

Phone Number


Relationship

II. Medical History

Primary Physician

Physician Phone Number

Have you been diagnosed with any medical conditions?

Are you currently taking any medications?

Do you have any allergies?

Have you had any surgeries?

Do you use any assistive devices (e.g., cane, walker, wheelchair)?

III. Mobility Concerns

What is your primary reason for seeking physical therapy?

How long have you been experiencing mobility issues?

Rate your current mobility on a scale of 1-10 (1 = very poor, 10 = excellent).

What activities are most difficult for you due to mobility issues? (Check all that apply)

Have you received physical therapy before?

IV. Pain Assessment

Do you experience pain related to your mobility issues?

If yes, please describe


What makes your pain better or worse?

V. Therapies Offered

Please review the following therapies and indicate your interest or concerns.

Therapy

Description

Interested?

Concerns?

Notes/Comments

Manual Therapy
Hands-on techniques to improve joint and soft tissue mobility
 
Therapeutic Exercise
Customized exercises to improve strength, flexibility, and balance
 
Gait Training
Training to improve walking patterns and reduce fall risk.
 
Aquatic Therapy
Exercises performed in water to reduce joint stress and improve mobility
 
Electrical Stimulation
Use of electrical currents to reduce pain and improve muscle function
 
Ultrasound Therapy
Use of sound waves to promote healing and reduce inflammation
 
Heat/Cold Therapy
Application of heat or cold to reduce pain and inflammation
 
Dry Needling
Use of thin needles to relieve muscle tension and pain
 
Yoga/Pilates
Mind-body exercises to improve flexibility, strength, and balance
 
Balance Training
Exercises to improve stability and prevent falls
 
Postural Training
Techniques to improve posture and reduce strain on the body
 
Assistive Device Training
Training on proper use of canes, walkers, or other devices
 

VI. Goals and Preferences

What are your primary goals for physical therapy? (Check all that apply)

Do you have any preferences for the type of therapy?

Are there any activities you would like to return to? (e.g., sports, hobbies)

VII. Lifestyle and Habits

What is your typical activity level?

Do you smoke or use tobacco products?

Do you consume alcohol?

Do you exercise regularly?

VIII. Additional Information

Is there anything else you would like us to know about your health or mobility?

IX. Consent and Signature

I consent to participate in physical therapy and understand that the information provided will be used to create a personalized treatment plan.

Client Signature

Form Template Insight

Please remove this form template insight section before publishing.


Below is a detailed breakdown of the Physical Therapy Mobility Intake Form, including insights into its purpose, structure, and the importance of each section. This form is designed to gather comprehensive information to ensure the therapist can create a safe, effective, and personalized treatment plan for the client.


Purpose of the Form

The primary goal of this intake form is to:

  1. Understand the Client’s Medical and Mobility History: To identify any underlying conditions, past injuries, or surgeries that may impact therapy.
  2. Assess Current Mobility and Pain Levels: To determine the severity of mobility issues and pain, and how they affect daily life.
  3. Identify Client Goals: To align therapy with the client’s personal objectives, such as reducing pain, improving balance, or returning to specific activities.
  4. Evaluate Suitability for Therapies: To ensure the chosen therapies are safe and appropriate for the client’s condition and preferences.
  5. Establish a Baseline: To track progress over time and measure the effectiveness of the therapy.

Detailed Insights into Each Section

1. Client Information

Purpose: Collects basic demographic and contact information for communication and record-keeping.

Insight: Emergency contact information is critical in case of unforeseen issues during therapy.


2. Medical History

Purpose: Identifies any pre-existing conditions, medications, allergies, or surgeries that may influence therapy.

Insight:

  • Medications (e.g., blood thinners) may contraindicate certain therapies like dry needling.
  • Allergies (e.g., to latex) are essential to note for safety during hands-on therapy.
  • Surgeries (e.g., joint replacements) may require modifications to exercises or techniques.

3. Mobility Concerns

Purpose: Assesses the nature and duration of the client’s mobility issues and their impact on daily life.

Insight:

  • Understanding the duration of issues helps differentiate between acute and chronic conditions.
  • Identifying specific difficult activities (e.g., climbing stairs) allows for targeted therapy.

4. Pain Assessment

Purpose: Evaluates the location, intensity, and frequency of pain to tailor pain management strategies.

Insight:

  • Pain patterns (e.g., worse in the morning) can indicate specific conditions like arthritis.
  • Understanding what alleviates or exacerbates pain helps in designing effective interventions.

5. Therapies Offered

Purpose: Introduces the client to available therapies and assesses their interest and concerns.

Insight:

  • Clients may have preconceived notions or fears about certain therapies (e.g., dry needling).
  • This section ensures the client is comfortable and informed about their treatment options.

6. Goals and Preferences

Purpose: Aligns therapy with the client’s personal objectives and preferences.

Insight:

  • Goals (e.g., returning to a sport) help prioritize therapy components.
  • Preferences (e.g., aversion to water) ensure the client is comfortable and engaged.

7. Lifestyle and Habits

Purpose: Provides context about the client’s daily activity level, habits, and overall health.

Insight:

  • Sedentary clients may require a more gradual approach to exercise.
  • Smoking or alcohol use can impact healing and recovery.

8. Additional Information

Purpose: Captures any other relevant details the client wishes to share.

Insight:

  • Clients may disclose information not covered in previous sections (e.g., recent emotional stress) that could impact therapy.

9. Consent and Signature

Purpose: Ensures the client understands and agrees to participate in therapy.

Insight:

  • Legal and ethical requirement to obtain informed consent.
  • Establishes a formal agreement between the client and therapist.

Key Features of the Form

  1. Comprehensive yet Concise: Covers all essential areas without being overly lengthy.
  2. Client-Centered: Focuses on the client’s goals, preferences, and comfort.
  3. Therapist-Friendly: Organizes information logically for easy reference and treatment planning.
  4. Safety-Oriented: Identifies potential contraindications and risks.
  5. Progress Tracking: Establishes a baseline for measuring improvements over time.

How Therapists Use This Information

  1. Personalized Treatment Plans: Tailors therapies to the client’s specific needs, goals, and medical history.
  2. Risk Management: Avoids therapies that may be unsafe due to medical conditions or medications.
  3. Client Engagement: Ensures the client is comfortable and invested in their therapy.
  4. Outcome Measurement: Tracks progress and adjusts the plan as needed.

Example Scenario

A 65-year-old client with knee osteoarthritis completes the form. The therapist learns:

  • The client has difficulty climbing stairs and rates their mobility as 4/10.
  • They experience moderate pain (6/10) in their knees, worsened by prolonged standing.
  • They are interested in aquatic therapy but concerned about dry needling.
  • Their goal is to reduce pain and return to gardening.

Based on this information, the therapist designs a plan focusing on:

  • Aquatic therapy to reduce joint stress.
  • Strengthening and balance exercises to improve mobility.
  • Education on pain management techniques.

This intake form is a critical tool for ensuring effective, safe, and client-centered physical therapy. It fosters clear communication, builds trust, and sets the foundation for successful outcomes.

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