Allegheny Chesapeake Physical Therapy

When your body needs repair...
1-800-NEW-SELF

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New Patient Information and Intake Forms

What can I expect on my first visit?

You will be asked to arrive for your appointment about 15 minutes early to complete paperwork. Your therapist will perform a comprehensive evaluation consisting of a detailed history of your condition and physical examination.

When your evaluation is complete, your therapist will develop a unique treatment plan that is customized for you and your condition. You and your therapist will develop goals to accomplish during your episode of therapy.

Patient Information Form

To complete this form, enter personal information, insurance information (can be found on your insurance card), and physician information. If a physician did not refer you to physical therapy, enter your primary care physician’s information.

Download Patient Information Form (PDF Document 62 Kb)

Medical History

In order to complete a thorough initial evaluation, your therapist requires your medical history. Complete this form to the best of your ability. It is imperative you notify your therapist of any medical complications, current medications, and allergies.

Download Medical History Form (PDF Document 154 Kb)

Pain Drawing

Carefully follow the directions on the form. Complete this form the day of your evaluation so your therapist will have the most accurate illustration of your pain.

Download Pain Drawing (PDF Document 58 Kb)

Patient Authorization

Read form carefully and sign/date on the applicable lines.

Download Authorization of Treatment Form (PDF Document 144 Kb)