New Patient Intake

Book your appointment

Complete this form so Dr. Naqvi can review your case before your first session. Most patients hear back within 24 hours.

01 — Personal Information

First Name *

Last Name *

Email *

Phone *

Date of Birth *

Sex

Occupation

Address (for in-home visits)

02 — Visit Details

Visit Type *

In-Home Evaluation Telehealth Evaluation In-Home Follow-Up Telehealth Follow-Up

Preferred Day(s)

Mon Tue Wed Thu Fri Sat

Preferred Time

Payment Method *

Cash / Self-Pay Out-of-Network Insurance

Insurance Provider (if applicable)

03 — Medical History

Primary Reason for Visit *

Where is your pain/discomfort? *

Neck Upper Back Lower Back Shoulder Elbow/Wrist Hip Knee Ankle/Foot Other

Current Pain Level (0 = no pain, 10 = worst imaginable)

No painWorst imaginable

How long have you had this condition?

Less than 1 week 1–4 weeks 1–3 months 3–6 months 6+ months

Have you had previous treatment for this condition?

Current Medications

Relevant Medical History

Diabetes Heart Disease High Blood Pressure Arthritis Previous Surgery Cancer Osteoporosis None

04 — Your Goals

What activities are limited by your condition?

What are your goals for physical therapy?

How did you hear about Dr. Naqvi?

Anything else Dr. Naqvi should know?

By submitting this form, you consent to Dr. Noman Naqvi reviewing your information to prepare for your appointment. Your data is kept confidential and used solely for treatment purposes. View pricing & insurance info.

Dr. Naqvi will review your case and respond within 24 hours.

Request received!

Thank you for submitting your information. Dr. Naqvi will review your case and reach out within 24 hours to confirm your appointment.

Cash or Out-of-Network Insurance

Response Within 24 Hours

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