Name:
Date: Today
To evaluate your condition fully, please complete the questions as accurately as possible. Thank you!
Height:
Weight:
1. Occupation:
Age:
Hobbies/activity:
2. What is your primary concern that brings you here?
3. When did your symptoms begin or worsen (date)?
4. What caused your symptoms to begin or injury to occur?
Have you had surgery for this injury? YES / NO
If yes, when (date)?
5. What makes your symptoms worse (positions/activities/time of day)?
6. What improves your symptoms (positions/activities/time of day)?
7. Have you previously had treatment for this concern?
If yes, did the treatment help?
What did the treatment consist of?
YES / NO
YES / NO
8. Have you had any diagnostic tests for this problem? (x-ray, MRI, CT scan, Bone Scan, Ultrasound, lab) YES / NO
If so, what were the results?
9. Where is your pain? Please draw on body diagram
Please rate and describe your pain
Current pain:
Worst pain last 24 hours:
Best pain last 24 hours:
_2__/10
_6__/10
_0__/10
My symptoms bother me:
Constantly
Occasionally Rarely
What does your pain feel like:
Sharp Stabbing Shooting Throbbing
Burning Aching Other_____________
My pain is getting:
Better Staying the same Worse
10. Have you recently been experiencing: (circle all that apply)
tremors / seizures
constipation/diarrhea
pain that worsens at night
nausea/vomiting
blood in stools/urine
night sweats
problems sleeping
easy bruising
changes in bowel/bladder function
headaches
breathing problems
unexplained weight loss/gain
dizziness / lightheadedness
excessive bleeding
hearing difficulty
fatigue / weakness
skin rash
vision changes/ eye redness
fever/chills/sweats
regular cough
heartburn/indigestion
numbness/tingling
heart racing in your chest
difficulty swallowing/chewing
sensation changes
pregnant/think you might be pregnant
11. History of tobacco use? YES / NO
This information will be used to help guide your treatment plan.
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12. Have YOU ever been diagnosed with the following conditions? (circle all that apply):
Depression
Pacemaker
Fibromyalgia
Anxiety
Heart Problems
Cancer
Chemical dependency
Lung problems/asthma
Stroke
ADHD
High Blood Pressure
Spinal Cord Injury
Anemia
High cholesterol
Tuberculosis
Diabetes
Chest pain/angina
Hepatitis
Head injury
Blood Clots
Kidney Disease/Stones
Chronic Headaches/Migraines
Circulation Problems
Fainting Disorders
Balance disorder/Vertigo
Bleeding/bruising
Stomach Ulcers
Epilepsy/Seizures
Rheumatoid Arthritis
Polio/muscle disease
TMJ disorder
Other Arthritic Condition
Thyroid Problems
Hernia
Lyme’s Disease
Multiple Sclerosis
Osteoporosis/Osteopenia
Pacemaker
Urinary Tract Infection
Gynecological disorders
Urinary Leaking/Frequency/Urgency
Parkinson’s Disease
Other medical condition(s):
13. List surgeries or other conditions for which you have been hospitalized and approximate date
14. List significant injuries for which you have been treated (fractures, dislocations, sprains) and approx. date
15. List medications you are currently taking (including pills, injections, skin patches, other).
16. List allergies:
Are you latex sensitive?
YES / NO
17. Currently, are any of your daily or recreational activities affected? YES NO If yes, specify:
18. Social Services Questions:
• Are you comfortable with your reading ability?
YES / NO
• How do you learn best? (Check all that apply)
a. Read_____ See_____ Do_____ Pictures_____
• Are you comfortable with your weight/body image?
YES / NO
• Are you afraid physical activity will cause an increase in your pain?
YES / NO
• Are you afraid that moving your injured area will be harmful to you?
YES / NO
• Are you having difficulties sleeping? Average hours of sleep/night:
YES / NO
• Do you exercise, outside of work duties, at least 2-3 times per week?
YES / NO
a. Would you like more info on improving your health with exercise?
YES / NO
• During the past month have you been feeling down, depressed or hopeless?
YES / NO
• During the past month have you been bothered by having little interest or pleasure
in doing things?
YES / NO
• Do you ever feel unsafe at home or has anyone hit you or tried to injure you in any way? YES / NO
19. What are your goals for physical therapy? (pain, activities, movement, preparation for event, etc.)
This information will be used to help guide your treatment plan.
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