Fill Out Online & Email

Complete your intake packet digitally. When finished, click the Submit Completed Intake Forms button and the completed information will be emailed directly to Princeton Physical Therapy.

How this sends: Fill out all pages below, then click the Submit Completed Intake Forms button. The form gathers the completed fields and WordPress emails them to Princetonpt@yahoo.com. Questions? Call (660) 748-3600. You may also click “Print / Save as PDF” to keep a copy for your records.

PHYSICAL THERAPY INTAKE FORM

PATIENT INFORMATION
Preferred Contact Method:
Gender:
Marital Status:
INSURANCE INFORMATION
How did you hear about us?
CHIEF COMPLAINT / CURRENT PROBLEM
What is the primary reason you are seeking physical therapy today?
Please rate your pain: /10 /10 /10
PAIN / SYMPTOMS
Type of pain: check all that apply
How often do you experience the pain?
Do you have pain at night? Does pain interfere with sleep?
Do you experience any of the following?
FUNCTIONAL LIMITATIONS
Are you working?
Work Requirements:
GOALS FOR THERAPY
PRIOR TREATMENT
Have you had prior treatment?
Did it help?
PAST MEDICAL HISTORY
PAST SURGICAL HISTORY
MEDICATIONS & ALLERGIES
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FULL BODY PAIN PROFILE

BODY PAIN MAP & PROGRESSION

My Body Pain Profile

Click a body area to show a pain point. Complete the table to update the map labels.

Tap or select painful areas
Body AreaPain?InitialCurrentType / Notes
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OUTPATIENT PHYSICAL THERAPY CONSENT FORM

OUTPATIENT PHYSICAL THERAPY CONSENT FORM

Please read the following information carefully. It is important that you understand the purpose and nature of physical therapy treatment and give your consent to care.

1. NATURE OF PHYSICAL THERAPY SERVICES
Physical therapy is a health care service that aims to evaluate, treat, and help prevent impairments, functional limitations, and disabilities related to movement and physical function.
2. BENEFITS AND RISKS
The goal of physical therapy is to improve your condition and help you return to your prior level of activity. Treatment can include temporary soreness, fatigue, dizziness, skin irritation, bruising, or increased pain.
3. TREATMENT MODALITIES — Please initial next to each modality to indicate your consent.
Please InitialModalityDescription & Potential Risks
4. PATIENT RESPONSIBILITIES
I understand that I am responsible for providing accurate information, asking questions, following recommendations, reporting changes, and communicating openly.
5. RELEASE OF INFORMATION
I authorize Princeton Physical Therapy & Sports Medicine to communicate with other healthcare providers as necessary for continuity of care.
6. CONSENT FOR TREATMENT

I have read and understand the information above. I voluntarily consent to receive outpatient physical therapy services.

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HIPAA NOTICE OF PRIVACY PRACTICES
ACKNOWLEDGMENT & AUTHORIZATION
1. PATIENT INFORMATION
2. ACKNOWLEDGMENT OF RECEIPT OF PRIVACY PRACTICES

I acknowledge that I have received or been offered a copy of the Notice of Privacy Practices for Princeton Physical Therapy & Sports Medicine, LLC.

3. AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION (PHI)
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Treatment, planning and coordination of care
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Payment and billing for services
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Healthcare operations and administrative functions
4. PERMISSION TO COMMUNICATE
5. AUTHORIZED INDIVIDUALS (OPTIONAL)
6. PATIENT RIGHTS

I understand that I have the right to request restrictions, confidential communications, copies of my records, and corrections.

7. CONSENT AND UNDERSTANDING

I understand that my information will not be shared without my permission except as allowed by law. I may revoke this authorization in writing.

8. SIGNATURE
FOR OFFICE USE ONLY

Ready to send?

Click the button below to email the completed intake packet to Princeton Physical Therapy.

Questions? Call (660) 748-3600

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