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
Job Opening

Please complete the following form and submit BEFORE your first visit. This will save you time before your appointment, and help the therapist, as he/she can review your answers before your visit. Thank you.

New Patient
Pre-Exam Form
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.

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:
Mon. - Fri 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
Job Opening