In order to make your time most efficient when in our clinic we hope you can complete and submit our intake form. We appreciate you taking them time to fill this out and provide you therapist valuable information.

AzPTS Intake and Screening Form

PATIENT INFORMATION

Name *

Name

First Name

Last Name

Today's Date *

Today's Date

YYYY

Date of Birth *

Date of Birth

YYYY

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Last 4 Digits of Social Security Number *

Mobile Phone

(###)

###

####

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Email Address *

Reminders for Appointments

Text Message

Phone Call

Cell Phone Carrier

Verizon

ATT

Sprint

T-Mobile

Other

Employer

Employer Phone Number

(###)

###

####

PHYSICIAN

Referring Physician

Primary Physician

EMERGENCY CONTACT

Emergency Contact *

Emergency Contact Relationship *

Emergency Contact Phone *

Emergency Contact Phone

(###)

###

####

HOW DID YOU HEAR ABOUT US?

Choose any that apply

Web Search

Friend

Medical Provider

Brochure

Other

HEALTH HISTORY

Other

Is this visit a result of a surgery?

Yes

PATIENT HEALTH QUESTIONNAIRE

When was your last physical examination? (estimate if needed) *

When was your last physical examination? (estimate if needed)

YYYY

Do you smoke cigarettes?

Yes

During the past 4 weeks, how much has pain interfered with your normal work (including both work outside the home, and housework) *

Not at all

A little bit

Moderately

Quite a bit

Extremely

During the past 4 weeks, how much of the time has your condition interfered with your social activities like visiting with friends, relatives, etc *

All of the time

Most of the time

Some of the time

A little of the time

None of the time

In general, would you say your overall health right now is *

Excellent

Very good

Good

Fair

Poor

Who have you seen for your symptoms? *

No one

Medical doctor

Chiropractor

Physical Therapist

Other

Other:

Have you had similar symptoms in the past? *

Yes

If you have received treatment in the past for the same or similar symptoms, who did you see?

This office

Medical Doctor

Physical Therapist

Chiropractor

Other

What is your occupation?

Occupation Type

Professional/Executive

White Collar/Secretarial

Tradesperson

Laborer

Homemaker

Full Time Student

Retired

Other

Other:

If you are not retired, a homemaker, or a student, what is your current work status?

Full time

Part time

Self-employed

Unemployed

Off work

Other

Other:

During the past month, have you often been bothered by feeling down, depressed, or hopeless *

Yes

During the past month, have you often been bothered by little interest or pleasure in doing things? *

Yes

CURRENT MEDICATIONS

How many prescription drugs do you take currently? *

Please bring list of your current presription drugs in with you, or provide us with drug name, dosage, frequency, and reason taking in a list form below

PATIENT SPECIFIC FUNCTIONAL SCALE - please identify 3 important activities that your are unable to do or are having difficulty with as a result of your current problem

Activity 1 *

Activity 2 *

Activity 3 *

Fall History

Injury is a result of a fall in the past year? *

Yes

Two or more falls in the past year *

Yes

Do you live _____

Alone

Spouse

Roommate

Other:

Other

Are their stairs in your home?

Yes

Arizona Physical Therapy Specialists

Physical therapists specializing in the injured golfer, spinal care, and chronic pain conditions.

Meet Our Therapists:

Tim Fearon PT DPT FAAOMPT

Ryan Hamic PT DPT OCS

David Roessler PT

Lauri Lazarus PT

AZ Physical Therapy Specialists
6245 N 24th Pkwy Suite 105
Phoenix AZ 85016
(602) 997-7844

Conveniently located at 24th st and Lincoln

Arizona Physical Therapy Specialists

Arizona Physical Therapy Specialists

Intake screening form

Arizona Physical Therapy Specialists

Arizona Physical Therapy Specialists

Meet Our Therapists:

AZ Physical Therapy Specialists6245 N 24th Pkwy Suite 105Phoenix AZ 85016(602) 997-7844

AZ Physical Therapy Specialists
6245 N 24th Pkwy Suite 105
Phoenix AZ 85016
(602) 997-7844