Physical Therapy in Hampton Roads
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In Motion Patient Forms

Save time on your first visit and fill out our forms in advance. Everyone should fill out the patient registration, medical history and personal representative/medical record forms.

Physical Therapy

  • Patient Forms
    • All patients attending Southside clinics (Carollton, Chesapeake, Norfolk, Portsmouth, Suffolk and Virginia Beach) access forms here
    • All patients attending Peninsula clinics, access forms here
    • Health Summary Form
    • What it is: Patient history at-a-glance that helps our experts treat you effectively.
      Tip: Include all your allergies, prescription medications, and other relevant medical information at the bottom of the form, so our team can ensure you receive the best care possible. Our therapist will review this form with you during your first appointment.
    • Medical History Form
      What it is: A questionnaire that helps us to understand the big picture of your health.
    • Patient Registration Form
      What it is: Your basic information, the first building block of your patient file.
      Tip: At the bottom of the form, patients are asked if they have Advanced Directive documents, which include your Living Will and your Medical Power of Attorney plan.
    • Personal Representative Form/Medical Records Request
      What it is: This is a very important form. It should be completed by the patient, or guardian if the patient is under 18.
      Tip: The patient contact information at the bottom of the form lets you or your personal representative tell In Motion exactly how you want to be contacted.
    • Patient Responsibilities
      What it is: This form lets you know what we expect from our patients during appointments and what you can expect from us.
      Tip: By being a responsible patient, we can work together to provide the best possible care and therapeutic outcomes.

Pelvic Health Program

    • Patients referred for the Pelvic Health program (women’s health, incontinence, pelvic pain), often referred by OB/GYN or Urologist, access forms here: Southside Packet and Peninsula Packet

**You can call the physical therapy clinic directly to schedule your initial evaluation with Direct Access, now available at our Southside locations, Norfolk, Virginia Beach, Chesapeake, Suffolk and Portsmouth. Get more information about Direct Access.

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