Furnace Brook Physical Therapy

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Specialized Programs

How Physical Therapy can Help You

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Part 1 of 5 - Patient Information


Patient Name *
Address *
City *
State *
Zip *

Home Phone *		(ex: 123-456-6789)
Cell		(ex: 123-456-6789)
Date of Birth *		(ex: 12/1/08)
SS#		(ex: 123456789)
Sex *		Male
		Female

Referring Physician *
Primary Physician *
Diagnosis *		(present Injury)

Employer *
Address
City
State
Zip
Phone *		(ex: 123-456-6789)

Emergency contact *		(ex: 123-456-6789)
Phone *		(ex: 123-456-6789)

Injury Result of Accident *		Yes
		No
		If yes, Work Comp
		If yes, Auto
		If yes, Date of Injury	(ex: 12/12/07)
Have you had Physical Therapy before? *
		Yes
		No
		If yes, where?
		If yes, when?	(ex: 12/07)
		If yes, Insurance type

* = required information
If this information is correct, please click "Save and Continue" to save move to section 2.

How Furnace Brook Physical Therapy Can Help You

Specialized Programs
Raise the Roof is a program that is ideal for any young female athlete who participates in a sport that may include stop/starts, pivoting and jumping.

Treating Plantar Fasciitis
Does your heel hurt you first thing in the morning? Read our Patient Education page on how physical therapy can help your painful foot, as well as several other common injuries.

Postoperative Rehabilitation
Referrals include status post neck and back surgery/ fusions; shoulder, elbow, knee and ankle reconstructive procedures; and following total joint replacement.