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WELCOME!

NEW PATIENT INTAKE FORM

step 1

stafford phyiscal therapy new patient in-take form

Thank you for your interesting in Stafford Physical Therapy. All new patients must complete the following forms before beginning treatment with Stafford Physical Therapy.

New Patient In-Take Form (right)

Notice of Privacy Practices for Protected Health Information (PHI)

Stafford Physical Therapy Policy Agreement

Please feel free to Contact Us with any additional questions or concerns.

- Step 1 of 5

First Name

Middle Name

Last Name

Date of Birth//

Patient Gender

Male
Female
Other

Social Security Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone

Home Phone

Email *

Multiple Choice

Single
Married
Widowed
Divorced

How did you hear about us?

Occupation

If dependent, please list parent's employer.

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Work Phone

Emergency Contact

Relationship

Primary Care Physician

Phone Number

Referring Physician

Phone Number

Is the patient also responsible for the account?

Is the patient responsible for decisions in treatment and payment?

Account Holder

Please tell us the name of the individual responsible for this account.

Account Holder Date of Birth

Account Holder Phone

Account Holder Address

Address Line 1

Address Line 2

City

State

Zip Code

What's the reason for your visit?

Work-related injury
Motor vehicle accident
Unknown cause
Recurrence of previous injury
Injury related to lifting
Athletic or recreational injury
Injury related to falling
Other

Please check all that apply.

If you selected "other" above, please explain.

Date of Injury

Date of Surgery

If applicable.

Attorney

Attorney Phone Number

Workers' Compensation Provider

Workers' Compensation Case Manager / Adjustor Name

Workers' Compensation Case Number

Phone Number

Fax Number

Height

Weight

Checkboxes

Diabetes
Chest pain / Angina
High blood pressure
Heart disease
Allergies / poor tolerance to cold
Pacemaker
Headaches
Cancer
Osteoperosis
Metal implants
Surgeries
Skin abnormalities
Sexual dysfunction
Nausea / vomiting
Ringing in your ears
Rheumatoid Arthritis
Heart attack
Heart palpitations
Allergies
Allergies to heat
Hernia
Seizure
Kidney problems
Osteoarthritis
Hypoglycemia
Special diet guidelines
Bowel / bladder guidelines
Urine leakage
Asthma / breathing difficulties
Liver / gallbladder problems
Smoking
Stroke / CVA

Please explain and give approximate dates for any of the aforementioned conditions.

Please include past surgeries with dates.

Please list all prescribed medications and non-prescribed medications you are currently taking.

Please include medication, dosage, frequency and administration (oral, injection, etc.).

Please describe your present symptoms and complaints.

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STAFFORD

572 Garrisonville Road, Stafford, Virginia 22554

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FREDERICKSBURG

1206 Bragg Road, Fredericksburg, Virginia 22407

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About US

Stafford Physical Therapy is a family-owned and operated physical therapy clinic that’s served patients in the Fredericksburg, Spotsylvania and Stafford region since 1987.

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