Mobility Improvement Physical Therapy Client Intake Form
I. Client Information
First Name
Last Name
Date of Birth
Phone Number
Email Address
Street Address
City/Suburb
State/Province
Postal/Zip Code
Emergency Contact Name
Emergency Contact Phone
Primary Care Physician
Physician Phone Number
II. Reason for Seeking Physical Therapy
What are your primary mobility concerns? (Please be specific)
When did you first notice these concerns?
How have these concerns impacted your daily life?
What are your goals for physical therapy?
Increased walking distance
Reduced pain
Improved balance
Other:
Do you have a doctor's referral?
III. Medical History
List any current medical conditions:
List any past surgeries or hospitalizations:
List any current medications (including dosage):
Do you have any allergies?
Do you have any history of:
Cardiovascular disease?
Diabetes?
Arthritis?
Osteoporosis?
Neurological conditions? (e.g., stroke, Parkinson's disease, multiple sclerosis)
Balance disorders?
Respiratory conditions?
Any history of falls?
Do you have any implanted medical devices? (e.g., pacemaker, joint replacement)
Are you currently experiencing any pain?
Please rate your current pain level on a scale of 0-10 (0 = no pain, 10 = worst pain imaginable)
IV. Lifestyle and Activity Level
What is your current activity level?
Sedentary
Light activity
Moderate activity
Active
Other:
Describe a typical day in your life:
What are your hobbies or recreational activities?
Do you use any assistive devices? (e.g., cane, walker, wheelchair)
Do you experience any difficulty with:
Walking?
Stairs?
Standing?
Sitting?
Transfers (e.g., bed to chair)?
Reaching?
Grasping?
V. Therapy Suitability Assessment
Please indicate your interest and suitability for the following therapies:
Manual Therapy (Joint Mobilization, Soft Tissue Mobilization):
Interest Level:
High
Medium
Low
Not Interested
Do you have any concerns about hands-on treatment?
Do you have any skin sensitivity?
Therapeutic Exercise (Strength Training, Flexibility Training, Balance Exercises):
Interest Level:
High
Medium
Low
Not Interested
Do you have any limitations that might affect your ability to perform exercises?
Do you have any pain when performing exercises?
Neuromuscular Re-education (Gait Training, Balance Training, Coordination Exercises):
Interest Level:
High
Medium
Low
Not Interested
Do you have any concerns about your balance or coordination?
Modalities (Ultrasound, Electrical Stimulation, Heat/Cold Therapy):
Interest Level:
High
Medium
Low
Not Interested
Do you have any sensitivities to heat, cold, or electrical stimulation?
Do you have a pacemaker or other implanted electrical device?
Aquatic Therapy (If Available):
Interest Level:
High
Medium
Low
Not Interested
Are you comfortable in water?
Do you have any skin conditions or open wounds that might be affected by water?
Assistive Device Training (Cane, Walker, Wheelchair):
Interest Level:
High
Medium
Low
Not Interested
Do you currently use or have you used any assistive devices?
Home Exercise Program:
Interest Level:
High
Medium
Low
Not Interested
Do you have the ability to perform exercises at home?
Do you have any concerns about performing exercises at home?
VI. Additional Information
Is there anything else you would like to share with your physical therapist?
What times of day are best for your appointments?
VII. Consent
I understand that the information provided in this form will be used to develop a personalized physical therapy treatment plan.
I consent to receive physical therapy treatment.
I understand that I can ask questions about my treatment at any time.
Client Signature
Important Considerations:
- This form should be reviewed and updated regularly.
- The physical therapist should conduct a thorough physical examination to complement the information gathered in this form.
- This form is for informational purposes, and does not replace professional medical advice.
This comprehensive intake form aims to get a complete picture of the client's health, lifestyle, and therapy preferences, ensuring a tailored and effective physical therapy plan.
Form Template Insight
Form Template Insight
Please remove this form template insight section before publishing.
Important Considerations:
- This form should be reviewed and updated regularly.
- The physical therapist should conduct a thorough physical examination to complement the information gathered in this form.
- This form is for informational purposes, and does not replace professional medical advice.
This comprehensive intake form aims to get a complete picture of the client's health, lifestyle, and therapy preferences, ensuring a tailored and effective physical therapy plan.
Let's break down the detailed insights into this Mobility Improvement Physical Therapy Client Intake Form, section by section.
1. Client Information:
Purpose: This section is foundational. It establishes basic contact and identification details. It's crucial for:
- Accurate record-keeping.
- Communication (scheduling, follow-ups).
- Emergency situations.
- Billing and insurance purposes.
Insights:
- Including emergency contact information is vital for safety.
- Gathering primary physician details facilitates communication and potential collaboration.
- Accuracy is paramount; double-check all information.
2. Reason for Seeking Physical Therapy:
Purpose: This section delves into the client's subjective experience and goals. It helps the therapist understand:
- The specific nature of the mobility issues.
- The impact on the client's daily life.
- The client's expectations from therapy.
Insights:
- "When did you first notice these concerns?" helps determine the chronicity of the issue.
- "How have these concerns impacted your daily life?" reveals the functional limitations.
- "What are your goals for physical therapy?" is essential for creating a patient-centered treatment plan.
- Doctor's referral information is important for insurance, and also communicates that another medical professional is also interested in the patients wellbeing.
3. Medical History:
Purpose: This is a critical section for identifying potential contraindications and risk factors. It helps:
- Assess the client's overall health status.
- Identify any underlying conditions that may affect treatment.
- Prevent adverse reactions to therapies.
Insights:
- A comprehensive medical history is essential for safe and effective treatment.
- Specific questions about cardiovascular, neurological, and musculoskeletal conditions are vital for mobility-related issues.
- Medication and allergy information is crucial to avoid harmful interactions.
- History of falls is very important, as it helps the therapist to understand the balance of the patient, and also to understand any fear based avoidance of movement.
4. Lifestyle and Activity Level:
Purpose: This section provides context about the client's daily routines and physical activity. It helps:
- Understand the client's baseline activity level.
- Assess the impact of mobility issues on their lifestyle.
- Tailor exercises and activities to the client's needs.
Insights:
- Understanding a "typical day" provides valuable insights into the client's functional demands.
- Information about hobbies and recreational activities helps motivate the client and incorporate enjoyable activities into therapy.
- Assistive device usage is crucial for determining the client's current level of independence.
- Questions about specific activities of daily living (ADLs) like walking, stairs, and transfers assess functional limitations.
5. Therapy Suitability Assessment:
Purpose: This section is designed to gauge the client's interest in and suitability for various therapy modalities. It helps:
- Personalize the treatment plan based on client preferences.
- Identify any potential contraindications or concerns related to specific therapies.
- Ensure informed consent.
Insights:
- Assessing "interest level" allows for a collaborative approach to treatment.
- Specific questions about concerns and sensitivities help avoid adverse reactions.
- Questions about implanted devices are crucial for safe use of modalities like electrical stimulation.
- Aquatic therapy questions are important for safety, and also for client comfort.
- Home program questions are important to understand the patients ability to continue their therapy outside of the clinic.
6. Additional Information:
Purpose: This section provides an opportunity for the client to share any additional relevant information. It also helps with scheduling.
Insights:
- Open-ended questions encourage clients to voice concerns or preferences.
- Scheduling preferences improve client satisfaction and adherence to therapy.
7. Consent:
Purpose: This section ensures that the client understands and agrees to the terms of treatment.
Insights:
- Informed consent is essential for ethical and legal reasons.
- It empowers the client to ask questions and be actively involved in their care.
Overall Insights:
- Patient-Centered Approach: The form emphasizes gathering information about the client's subjective experience and goals, promoting a patient-centered approach.
- Safety First: The medical history and therapy suitability sections prioritize safety by identifying potential contraindications and risk factors.
- Functional Focus: The lifestyle and activity level sections focus on functional limitations and the impact on daily life, ensuring that therapy addresses the client's specific needs.
- Comprehensive Assessment: The form covers a wide range of aspects, providing a holistic view of the client's health and mobility.
- Communication Tool: The form serves as a valuable communication tool between the client and the physical therapist, facilitating collaboration and shared decision-making.
By using this detailed intake form, physical therapists can create personalized and effective treatment plans that improve clients' mobility and quality of life.