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Initial Evaluation Form
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Email *
Full name / Address / Birthdate *
Effective 5/11, the Commonwealth of Massachusetts has lifted the COVID-19 public health emergency. Masks are no longer required but are welcome. 

Do you prefer that you and your physical therapist remain masked during your treatment session?
(Optional) What is your gender and what pronouns do you use?
Please provide a brief description of your current injury/condition and the approximate start date? *
What activities make the pain from your injury/condition worse? *
What activities make the pain from your injury/condition better?
Have you had a related surgery? *
If you had a related surgery, what was the date?
If you are having pain, please rate the intensity of your pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain possible.  What is the WORST your pain gets? *
What is your pain TODAY? *
What is the BEST (ie lowest) your pain gets? *
Are you currently employed?  If so, what is your profession? *
MEDICAL HISTORY Have you ever experienced or been diagnosed with (check all that apply) *
Required
If you checked any of the above, please describe
Please list all medications that you are presently taking *
Please list any allergies *
Do you participate in any sports, exercise programs, or activities on a regular basis?  If so, what and how often? *
In case of emergency,  whom should we contact?  Please give NAME, RELATIONSHIP TO YOU,  PHONE NUMBER? *
How did you find out about Outback Physical Therapy? *
I understand that I am requesting rehabilitative treatment and care from Outback Physical Therapy.  I understand that I have the right to ask and have any questions answered prior to receiving any treatment; including any risks or alternatives to the treatment plan.  By signing this agreement, I consent to have Outback Physical Therapy provide treatment and care as prescribed by my physician and/or recommended by my therapist. I understand, acknowledge and affirm that such rehabilitation and related services may involve bodily contact, touching and/or direct contact of sensitive nature.   *
 I know and agree that Outback Physical Therapy is not responsible for loss or damage to personal valuables. *
I hereby release, discharge and acquit Outback Physical Therapy, its agents, representatives, affiliates, employees, or assigns, of and from any and all liability, claim, demand, damage, cause of action, or loss of any kind arising out of or resulting from my refusal to accept, receive or allow emergency and or medical services, including but not limited to ambulance service, Emergency Medical Technician, physician or urgent care services. *
I hereby assign all benefits directly to and also authorize release of any medical records necessary to facilitate my treatment to process medical claims and as otherwise permitted or required in the Notice of Privacy Practices. I understand fully that in the event my insurance company or financially responsible party does not pay for the service I receive, I will be financially responsible for payment. *
I acknowledge receipt and agree to Outback PT’s notice of privacy practice (can be retrieved at https://tinyurl.com/outbackptHIPPA ) *
I acknowledge and agree to Outback PT's Billing policy (can be retrieved at https://tinyurl.com/OBPTBilling) and I will provide a credit card at the time of my first visit to be stored on file according to this policy. *
CANCELLATION POLICY: We understand that there are times when you must miss an appointment.  Please give us at least 24 hours notice, so that we can offer care to another patient on our waitlist.  There is a cancellation fee of $50 for late arrivals of 15 minutes or more, no-shows or appointments canceled with less than 24  hours notice unless rebooked in the same week. If you have 3 cancellations with less than 24 hours notice, we will ask that you call for a same day appointment, rather than booking ahead.  We thank you for your understanding.   *
I agree to opt in to receive text messages regarding appointments and billing. This will never be used for marketing purposes. 
 *
Entering my full name below serves as my signature that I agree to all aspects of this consent form *
If under age 18, parent/guardian full name below serves as consent for the patient.    
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