Patient questionnaire

Please complete the following form prior to attending your first scheduled appointment. 

Patient Questionnaire

List the location(s) of your symptoms.(Required)
Please enter a number from 1 to 10.
How would you describe your pain?(Required)
List significant past and current medical conditions (i.e. heart disease, cancer, pregnancy, pacemaker, spinal implants, etc).(Required)
List any goals you would like to achieve with Physical Therapy treatment.(Required)
List medications you are currently taking for this problem.(Required)
List any special test, such as Xrays, MRI, EMG, that you have had in regards to your current problem.(Required)
Is this work related as a worker's compensation claim?(Required)
Do you need to pre-certify for physical therapy services under your health care plan?(Required)
Are treatments provided by Floyd County Medical Center covered by your insurance?(Required)