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ABA Therapy
Speech Therapy
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- Adult Therapy Process
- Patient Forms
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Pontiac Office:

3000 Centerpoint Pkwy Pontiac, MI 48341

Dearborn Heights Office:

24142 W. Warren Road, Ste B. Dearborn Heights, MI 48127

Almost No Waiting for PT, Speech AND ABA SERVICES! CONTACT US TODAY!

Euro-Therapies

Almost No Waiting for PT, Speech AND ABA SERVICES! CONTACT US TODAY!

Euro-Therapies

Home
About Us
Pediatric Physical Therapy
ABA Therapy
Speech Therapy
Adult Physical Therapy
- Adult Therapy Process
- Patient Forms
Resources
Contact Us

Adult Physical Therapy Services Available From Euro-Therapies

Adult Physical Therapy at Euro-Therapies embodies our enduring dedication to fostering holistic well-being for our clients. Building upon over two decades of exemplary service within Euro-Peds, we are proud to extend our expertise to address the distinct needs of adult patients. With a foundational commitment to personalized care, our approach to physical therapy is rooted in the belief that every individual deserves a tailored path toward optimal health and mobility.

Adult Conditions We Treat With Physical Therapy

Adult Therapy Process

Patients Forms for Adult Physical Therapy

Contact Us

Patient Name:

Patient Name:

Date of Birth:

Age:

What is your current gender identity? (Check all that apply)

M

F

Transgender/FTM

Transgender/MTF

gender queer

decline to answer

Height:

Weight:

Address:

Preferred Phone # Home:

Cell:

E-Mail:

Emergency Contact Name/ Phone #:

Relationship:

HISTORY:

Please check the appropriate answer:

Do you have high blood pressure?

YES

NO

Do you currently have an infection?

YES

NO

Do you have Diabetes?

YES

NO

Do you currently have heart trouble?

YES

NO

Do you have asthma?

YES

NO

Do you have active cancer?

YES

NO

Are you pregnant?

YES

NO

Do you have other health problems?

YES

NO

If yes, please explain

Do you have significant allergies?

YES

NO

If yes, please list all allergies

Do you have seizures? If yes, please list the last time you had a seizure

Free Text

CURRENT STATUS:

Are you receiving other treatments for your problem currently?

YES

NO

If yes, please list

Have you had physical therapy previously for the same problem?

YES

NO

What kind of tests have been done for your current problems? (Check all that apply)

MRI

X-Ray

CT scan

EEG

Other tests, please list:

Please list all medications, dosage and frequency.

Please list all previous surgeries & dates preformed.

Free Text

PAIN:

Do you have pain now?

YES

NO

If yes, location/ type:

What makes the pain better?

What makes you pain worse?

Does the pain interfere with your daily life?

YES

NO

Rate your pain on a scale of 0-10 (0 being no pain and 10 begin the worst pain)

Free Text

BALANCE:

Have you had falls in the last 6 months?

YES

NOP

If yes, how many times?

Are you reluctant to leave your home because of fear of falling?

YES

NO

Free Text

GOALS:

What are your goals for attending physical therapy? (Check all that apply):

decrease pain

less difficulty with activities

sleep longer

improve movement

improve strength

stand longer

sit longer

return to recreational activity/sports

Other Goals not listed:

Free Text

EMPLOYMENT INFORMATION:

Are you currently working?

YES

NO

Option 3

If not, what was your last day of work?

Free Text

REFERRING DOCTOR OR INDIVIDUAL:

Referring Physician:

Address:

Phone:

Fax:

Primary Care Physician:

Address:

Phone:

Fax:

Is your chief complaint the result of an auto accident?

YES

NO

State the auto accident occurred in?

Was a police report filed?

YES

NO

Was an auto claim filed?

If yes, please provide claim #:

Auto Insurance Company:

Phone#

Adjustor Name:

Phone#

If yes, do you have Attorney representation?

YES

NO

Attorney Name:

Phone #:

Address:

Is your chief complaint the result of a work injury?

YES

NO

Is your injury the result of a slip and fall?

YES

NO

Please explain in detail how/ when your injury happened:

What is the date of your injury?

Free Text

INSURANCE INFORMATION:

Primary Insurance Company:

Subscriber:

Subscriber Date of Birth:

Employer:

Provider phone #:

Contract#:

Group #:

Secondary Insurance Company:

Subscriber:

Subscriber Date of Birth:

Employer:

Provider phone #:

Contract #:

Group #:

Patient or Personal Representative (PRINTED)

Please Upload Here

Patient or Personal Representative Signature Date

Thank you for contacting us.
We will get back to you as soon as possible.

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PHYSICAL THERAPY INTAKE FORM

Discover Whether Euro-Therapies May Benefit You or Your Loved One

Get a personalized head start. Call us now at (248) 857-6776 to schedule an appointment. Euro-Therapies accepts many insurances.

SERVICE AREAS

Auburn Hills
Berkley
Beverly Hills
Birmingham
Bloomfield Hills
Clawson
Dearborn Heights
Farmington Hills
Ferndale
Lake Orion
Madison Heights
Novi
Oak Park
Oxford
Pontiac
Rochester
Rochester Hills
Royal Oak
South Lyon
Southfield
Troy
Waterford
Wayne

CONTACT INFORMATION

Pediatric Therapy Center

Phone: (248) 857-6776

Alt: (248) 857-7137

Fax: (248) 857-7102

Email: info@euro-therapies.com

Address: 3000 Centerpoint Pkwy Pontiac, MI 48341

Mon - Thu: 9:00 am - 6:00 pm
Friday: 9:00 am - 3:00 pm
Sat - Sun: Closed

Pediatric Therapy Center

Phone: (248) 857-6776

Alt: (248) 857-7137

Fax: (248) 857-7102

Email: info@euro-therapies.com

Address: 4020 Venoy, Suite 1100, Wayne, MI 48184

Mon - Thu: 9:00 am - 6:00 pm
Friday: 9:00 am - 3:00 pm
Sat - Sun: Closed

Adult Physical Therapy

Phone: (313) 277-5508

Fax: (313) 277-5535

Email: info@euro-therapies.com

Address: 24142 W. Warren Road, Ste B.

Dearborn Heights, MI 48127

Mon - Thu: 9:00 am - 6:00 pm
Friday: 9:00 am - 3:00 pm
Sat - Sun: Closed

Visa Payment Accepted

MasterCard Payment Accepted

American Express Payment Accepted

Discover Payment Accepted

Cash Payment Accepted

Check Payment Accepted

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