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Fax: (406) 777-7040

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CONFLUENCE ATHLETIC THERAPY NEW PATIENT INTAKE AND CONSENT TO TREAT

First name

Last name

Email

Phone

Birthday

How active is your lifestyle? *

Sedentary

Moderately Active

Heavily Active

If employed, what is your job title?

Describe the activites involved in your job (sitting at a desk, heavy lifting, etc.

What sports or physical activities do you participate in?

On which side is the primary problem? *

RIGHT

LEFT

MIDLINE

BILATERAL

Where is the primary problem? * Required

JAW

NECK

SHOULDER

ELBOW

WRIST/HAND

MID BACK

LOW BACK

HIP

KNEE

FOOT/ANKLE

OTHER

If other area of the body, please describe

Please describe the onset of this condition *

Acute or result of an injury

Chronic or no mechanism of injury

Comes and goes

How long have you had this condition?

Have you received treatment for this condition before? *

Yes

No

If "yes" when and from whom?

Are you taking any medications?

In your own words, please give a detailed description of the history of this condition

Anything else you would like Confluence Athletic Therapy to know about?

If minor, name of legal guardian

I authorize Confluence Athletic Therapy to provide treatment for this condition

Your Signature

Thank you for your submission

Serving Bozeman and the Greater Gallatin Area

Hours:

Mon - Fri: 8:30am - 7pm

Saturday: By Appointment

Sunday: By Appointment

CONTACT

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