PRE PT FORMS-Chapman WebPT - Abilene Physical Therapy & Sports Rehab

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Home
Meet the Staff
Videos
Therapy Services
Other Services
Testimonials
Patient Center
Contact
Insurance/Billing
FAQ
Direct Access
Career

Please complete Form #1 below. Once you submit this form, you will be directed to the page for Form #2.

New Patient
Intake Form #1
In order to evaluate your conditon fully, please be as accurate as possible. Thank you

* Indicates required field

Name *

First

Last

Age *

Gender *

Male Female

Occupation *

Are you currently working? *

Yes No

Where is your pain/problem *

What caused your pain/problem? *

Approximately when did it start? *

List ONE ACTIVITY you are unable to do, that you absolutely want to be able to do again: *

In your understanding, what do you think will make it better? *

What are you expecting from therapy? *

List any Medications you are taking or bring a list to your 1st appointment: Please list the Name, Dosage, and Frequency *

Do you have a Pacemaker? *

Yes No

Please list all prior surgeries/recent hospitalizations that may affect treatment-with dates: *

list past surgeries and hospitalizations

Medical History (Check all that apply) *

No Known Significant Prior Medical History to Affect Treatment Alzheimer's Cardiovascular Disease Cauda Equina Syndrome Saddle Anesthesia Recent Onset Bladder Dysfunction Cerebral Vascular Accident Major Motor Weakness

. *

Current Infection Diabetes Mellitus Type 1 Diabetes Mellitus Type 2 Fibromyalgia Fracture or Suspected Fracture High Blood Pressure History of Cancer Huntington's

. *

Immunosuppression Lupus Muscular Dystrophy Obesity Osteoarthritis Parkinson's Rheumatoid Arthritis Traumatic Brain Injury

Comments on checked medical conditions/Other condition(s) not listed? *

By typing my name and phone number below, I agree that all the questions were answered to the best of my ability. I understand that I will have a chance to review this form with my therapist once I begin therapy.

Please type name and phone number and press the SUBMIT button. You will be directed to a new page for Form #2

Name *

First

Last

Phone Number *

Submit

The state of Kansas is a “Direct Access” state for Physical Therapy.
You can begin physical therapy with or without a referral from a physician.

Now With 2 Locations to Better Serve You!

103 Northwest 15th Street
Abilene, KS 67410
Phone: 785-263-3646
FAX: 785-263-3689

HOURS:
Monday - Friday
8:00 a.m - 5:00 p.m.

1030 North Marshall, Suite B
Chapman, KS 67431
Phone: 785-922-4016
FAX: 785-922-4018

HOURS:
Monday - 1 p.m. - 5 p.m.
Tuesday & Thursday 8 a.m. - 5 p.m.

Contact Us

Home
Meet the Staff
Videos
Therapy Services
Other Services
Testimonials
Patient Center
Contact
Insurance/Billing
FAQ
Direct Access
Career