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XCELERATE PHYSICAL THERAPY MEDICAL HISTORY FORM PATIENT NAME TODAY S DATE REFERRING PHYSICIAN S NAME DATE OF INJURY OR ONSET CAUSE OF INJURY OR ONSET ARE YOU PRESENTLY WORKING Y PRIMARY CARE PHYSICIAN S NAME N DATE OF NEXT MD APPT WHAT IS YOUR REASON FOR ATTENDING THERAPY BECAUSE OF YOUR PROBLEM WHAT SPECIFIC ACTIVITIES ARE YOU HAVING DIFFICULTY WITH WHAT ARE YOUR PERSONAL GOALS/OUTCOMES YOU HOPE TO ACHIEVE FROM THERAPY DESCRIBE YOUR GENERAL HEALTH circle one DO YOU USE TOBACCO circle one YES...
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Start by opening the Raintree Intake & Consent form.
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Read through the form carefully to understand the information required.
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Begin filling out the form by entering your personal details, such as name, address, and contact information.
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Move on to the consent section where you may be asked to provide consent for specific treatments or procedures.
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Fill in the necessary medical history information accurately, including any allergies or pre-existing conditions.
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Raintree intake amp consent is a form that must be completed by individuals who are seeking services or support from the Raintree organization.
Anyone who wishes to receive services or support from Raintree is required to fill out the intake amp consent form.
To fill out the raintree intake amp consent form, individuals must provide their personal information, reason for seeking services, and consent to receive the requested support.
The purpose of raintree intake amp consent is to gather necessary information from individuals seeking services from Raintree and to ensure that they consent to receive the support.
Information such as personal details, reason for seeking services, medical history, and contact information must be reported on the raintree intake amp consent form.
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