Patient Forms

Prior to your first visit with us at our SD physical therapy clinic, please take a few moments to complete your initial paperwork. Doing so will help us expedite your care and will save you time during your first appointment. Simply click on the button below to download and print!

Our forms are PDF files. To download and print the forms, you'll need the free Adobe Acrobat Reader program.

Medical Questionnaire

In order for you to truly benefit from your physical therapy in San Diego, it is important for us to first create a clinical profile for you. This will allow us to establish a safe and appropriate therapy program customized specifically for you. Your input is extremely important, so please fill out the following questionnaire as completely as possible.

Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Email*
Age
Dominant Hand
Present Symptoms
Please describe your complaints
How long have symptoms been present?
Date of onset
MM slash DD slash YYYY
If this was an injury, check the appropriate boxes
- Motor Vehicle Accident
- Work Injury
- Sports
- Other
- No Injury/Incident
Briefly describe how it happened here
What kind of pain are you experiencing? ( Check all the following that apply)
- Numbness
- Pins/Needles
- Shooting Pain
If two or more areas of pain, what area started first?
If two or more areas of pain, was there an injury for the second area?
- Yes
- No
If there was an injury for the second area, where was it?
Pain since onset (select one)
Frequency of pain?
- Constant
- Intermittent
If constant, does intensity vary?
- Yes
- No
Phone
This field is for validation purposes and should be left unchanged.

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Patient Forms

Medical Questionnaire

Present Symptoms