NEW PATIENT FORMS

In order to expedite our registration process, please fill out the following forms prior to your first Physical Therapy appointment. If you choose to submit the fillable forms, please let us know prior to your first appointment to confirm they have been received. 

New Patient Information

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Self Reported Medical History

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Have you ever had any of the following conditions? Please check all that apply.

Cancer

Eating Disorder(s)

Hypothyroid or Hyperthyroid

Heart Problems

Vision Problems

Headaches

High Blood Pressure

Hearing Problems

Diabetes

Adema

Stroke

Irritable Bowel Syndrome

Anemia

Seizures

Sexually Transmitted Disease

Low Back Pain

Arthritis

Physical or Sexual Abuse

Tailbone Pain

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Pelvic Pain

Alcoholism/Drug Abuse

Neck Pain

Other

Depression

Asthma

Smoking

Allergies

Since the onset of your condition, have you experienced any of the following:

Fever/Chills

Changes in bowel/bladder function

Unexplained weight changes

Unexplained tiredness

Dizziness or fainting

Unexplained muscle weakness

Night pain/sweats

Numbness or tingling

Other

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Ob/Gyn History (females only) Check all that apply:

Vaginal delivery

Difficult childbirth

Painful periods

false

Pelvic organ prolapse

Menopause

Episiotomy

Vaginal dryness

Painful vaginal penetration

Other

Uro History (males only) Check all that apply:

Prostate disorders

Pelvic pain

Painful ejaculation

Shy bladder

Erectile Dysfunction

Other

Please list all current medications.

If so, you MUST be discharged from Home Health prior to any outpatient services or your sessions will become patient responsibility

THE CLINIC

5252 Westchester St 

Suite 255

Houston, TX 77005

Phone: 713.360.0300

Fax: 713.661.0410

Email: info@BercuttPT.com

Hours:

Mon - Fri: 8am - 5pm

7am Appts. available on Tues. and Wed. 

​​Saturday: Closed ​

Sunday: Closed

CONTACT

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© Copyright 2015 Bercutt PT, All rights reserved