FILL & PRINT • PATIENT WORKSHEET

Patient intake

Prepare information for your first therapy visit. Leave anything you are unsure about blank and discuss it with your therapist.

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Fill out what you can, then print or save as PDF using your device’s print menu. Bring it to your visit. Nothing is sent to Swift. Closing or refreshing this page can clear your work.

Swift Rehabilitation, Inc.Maryland: (443) 323-0027 / (443) 469-3426 · New Jersey: (856) 856-4122

About you

Patient’s full nameDate of birthDate completedPreferred name / pronouns (optional)PhoneEmail (optional)Home / visit addressEmergency contact & relationshipEmergency contact phonePreferred language / communication needs

Your visit

Therapy requested (PT, OT, speech, or unsure)Preferred setting / stateReferring clinician and phone (if applicable)Insurance plan name (bring your card)Primary care clinician

Health history & goals

What brings you to therapy? When did it begin?Medical conditions, recent surgeries, and precautionsMedications and supplements (or bring a current list)Allergies / sensitivitiesFalls, balance concerns, and mobility aidsWhat activities are difficult? What are your goals?Anything else your therapist should know?

Patient / representative signature: ___________________________________

Date: ____________________ Relationship (if applicable): ____________________

This worksheet is for discussion with Swift. It does not confirm an appointment, establish treatment consent, or authorize release of records.

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