Social Security Number
Home Phone Cell Phone
Referring PhysicianPrimary Physician
Reason for your visit
Have you had physical therapy for this condition before?NoYesWhen
Have you had any physical therapy this year?NoYesWhen
Is this injury related to an auto or work accident?NoYesDate of Injury
Are you receiving any homecare services?NoYes
WC insurance Carrier
Adjusters Name Phone#
Patient Name Date of accident
City and state of accident
Carrier Case# WCB#
Private Insurance CarrierID#
Insured Name DOB:
What brings you to performax?
When did your symtoms occur and how?
Have you had physical therapy for this condition before?
If so, when?
If you are having pain?Constant (75%-100%)Frequent (50%-75%)Occasionally(25%-50%)Interminttent (lessthan 25% of time)
Can you rate your pain? If 0 is no pain at all and 10 is the worse pain you have ever felt where does your pain lie?012345678910
Have you had any falls in the last 12 months?NoYesWhen
Is there any past medical history we need to know about? (pacemaker, defibrillator, surgeries, etc.)
Do you have any allergies?
Please list any medications you are currently taking
Who can we thank for referring you to our office?