Core Physical Therapy

1971 Western Avenue Albany, NY  12203

Phone: (518) 869-6220

Fax: (518) 869-6465

Name______________________                                                Date of Birth_________________

Address ___________________                                                Telephone Number

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Occupation__________________                                                Work_________________

Insurance Carrier______________                                                Cell__________________

ID#____________________                                                Referring MD_______________ Date_____________                                                            MD phone__________________

What is your present complaint? ___________________________________________  ________________________________________________________________________

How long have you been with this complaint? ________________________________________________________________________

List your past surgeries or major medical problems: __________________________ ________________________________________________________________________________________________________________________________________________

Are you currently being seen for any other medical problems? If so, what are they?  ________________________________________________________________________________________________________________________________________________________________________________________________________________________

What have you tried to treat this problem before and was it beneficial, harmful, or not effective?

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What do you do that increases your complaint?

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What do you do that decreases your complaint?

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What are your goals for therapy?

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How did you hear about Core Physical therapy?

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