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Patient Intake Form

Private and Confidential

PATIENT INFORMATION (required)

Gender*
Marital Status*

REFERRAL INFORMATION

EMERGENCY CONTACT (required)

INSURANCE INFORMATION

Is this a Work Injury?
Is this an Auto Injury?

CURRENT CONDITION

What tests have been done?
Have you had 2 or more falls in the past year or fall with injury in the past year?

Personal health history

(Please read all and check all that apply to you)
RECENT
GENERAL

DAIGNOSED CONDITION

DESCRIBE YOUR HABITS

RATE YOUR DIET

OTHER CONDITIONS

BODY PAINS
CURRENT CONDITIONS

RATE YOUR PAIN

Current pain
HOSPITALIZATIONS/SURGERIES & DATES
CURRENT MEDICATIONS & SUPPLEMENTS

OUR PRIVACY POLICY

The office of Murray Physical Therapy and Sports Medicine is committed to upholding the security and confidentiality of personal information that you provide to us. We take responsibility of safeguarding your information very seriously. We do not share or sell patient information with anyone outside our office without your written consent. This policy covers information including personal, financial, or health information about a consumer or customer relationship.

I have been given a copy of the privacy policy of Murray Physical Therapy. I hereby authorize that my records of evaluation and treatment with the office of Murray Physical Therapy may be forwarded to referring physicians, specialists, or therapists, who are also involved in my healthcare. Your insurance claims will be transmitted through an electronic clearing house, in accordance with HIPAA regulations.

By agreeing below, I have read, or have had read to me, the above consent to evaluation and treatment statement, that I am aware of the privacy policy, and that I certify that my medical information above is correct to the best of my knowledge.