Sending Form

Patient Demographics

Emergency Contact


History of Present Conditions

Pain Drawing

Pain Rating - Please rate your pain in the scale below, circle the number that best represents your pain:

Feel Great
Nagging Pain
Hurts even more
Intense Horrible
0 Feel Great
1 - 2 Annnoying
3 - 4 Nagging Pain
5 - 6 Hurts even more
7 - 8 Intense Horrible
9 - 10 Unbearable

Patient Medical Screening Questionnaire

Eagle Physical Therapy is committed to providing quality physical therapy at reasonable cost. It is our policy to collect all accounts receivable within 90 days from date of service.

For those patients with insurance coverage, we bill regularly. However, the patient is responsible to understand the specifics of their individual insurance coverage. The insurance contract is between the covered individual and the insurance company. The patient retains ultimate responsibility for financial charges incurred as a result of treatment. Our staff is available for assistance with insurance billing questions.