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Pre-Evaluation Intake Questionnaire

In order to evaluate your condition fully, please be as accurate as possible.

Please review & answer the following questions to the best of your ability. All fields are required, if a field does not apply to you, please put “NA” or “None.”

Patient First Name

Patient Last Name

Patient Date of Birth

Month

Day

Year

Address

Email

Phone

Gender Pronouns

Occupation

Other Medical History (injuries, surgeries, conditions)

Where is your pain / problem?

What do you think caused your pain / problem?

Approximately when did the pain start?

List one or two activities you are unable to do, that you absolutely want to be able to do again:

Have you had this same / similar problem before? Describe how and approximately when.

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

What are some potential obstacles to you getting better?

What are you expecting from therapy?

List any medications you are taking:

Acknowledgement

I agree & understand that my candidacy for a rehabilitation program will be dependent upon my ability and willingness to improve. I have answered the questions above honestly and accurately to the best of my ability. The therapist will determine whether or not I am a viable candidate for a rehabilitation program and that my approval into their program is not guaranteed.

Today's Date

Month

Day

Year

Signature

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