801 Auburn Way North Suite E, Auburn WA 98002 253-736-2340 Fax: 253-736-2343
www.auburnsportspt.com
Patient History
Name________________________________ Male___ Female___ Today’s date_______________________
Age______Height________Weight_________Occupation_________________________________________
Are you currently off work because of this problem?________ If yes, last day worked___________________
Area of injury/symptoms__________________________ Date your symptoms started__________________
Is this an L & I or MVA (motor vehicle accident) claim? Yes____ No ____
How did your symptoms start?_______________________________________________________________
Diagnosis from your doctor_________________________________ Doctor recheck date________________
Rate your pain level:
No pain
1
2
3
4
5
6
7
8
9
10
Worst pain
Using the diagram, circle the specific area of pain. If pain travels, use
arrows.
Describe your pain:
Dull ache_______ Burning______ Heavy______
Deep ache______ Throbbing_____ Twinge_____
Stabbing_______ Squeezing_____ Cramp_____
Nagging________ Sharp_________ Sore ______
Other__________________________________
Do you have any numbness/tingling?_______ Where?___________________________________________
What eases the pain?_____________________________________________________________________
What aggravates the pain?_________________________________________________________________
Do you feel you are: getting better________ getting worse________ staying the same________?
Have you had x-rays, MRI or other tests? Yes_______ No______ Findings?_________________________
List any previous surgeries________________________________________________________________
What are your personal goals for physical therapy? (please circle all that apply)
1)
2)
3)
4)
5)
Decrease pain
Improve motion
Increase strength
Return to work
Improve sleep
6) Return to sports, hobbies, recreation
7) Learn proper body mechanics
8) Improve posture
9) Other (specify)_______________________
___________________________________
Please list ALL medications you are currently taking, prescription and over-the-counter, for this and any other
condition (including pills, injections and/or skin patches).
___________________________________________
_________________________________________
___________________________________________
_________________________________________
___________________________________________
_________________________________________
Do you smoke? Yes___ No___
Emergency Contact: _________________________ Relationship ____________Phone #_____________
Please fill out other side
Do you take time to exercise beyond normal daily activities and chores? Yes_____ No_____
How many days per week? ___Daily ____3-4 ____1-2____less than once per week
Describe the exercise(s)______________________________________________________________
Circle activities which are difficult for you and then check the appropriate box:
No difficulty
With difficulty/pain
Cannot do
Personal hygiene: hair, bathing, toilet
Dressing: zippers/buttons, upper body, lower
body, shoes
Household chores: reaching overhead,
lifting/carrying, dust, vacuuming, mopping
Meal preparation: using stove, doing dishes
Yard/Garden: mowing, weeding, raking,
watering
Walking: stairs, curbs, incline, decline,
uneven ground, distance
Transportation: driving self, ride with others,
bus, taxi, shopping
Have you or anyone in your immediate family EVER been diagnosed with any of the following?
YOU
FAMILY MEMBER (who)
A. Cancer (if yes, what kind?)
_______
_________________
B. Heart problems
_______
_________________
C. High blood pressure
_______
_________________
D. Asthma
_______
_________________
E. Emphysema
_______
_________________
F. Chemical dependency (e.g. alcoholism)
_______
_________________
G. Thyroid problems
_______
_________________
H. Diabetes
_______
_________________
I. Multiple Sclerosis
_______
_________________
J. Osteoarthritis
_______
_________________
K. Rheumatoid arthritis
_______
_________________
L. Depression
_______
_________________
M. Infectious disease (hepatitis, tuberculosis)
_______
_________________
N. Head injury
_______
_________________
O. Stroke
_______
_________________
P. Kidney disease
_______
_________________
Q. Anemia/Blood disorders
_______
_________________
R. Epilepsy/Seizures
_______
_________________
S. Fractures/Broken bones
_______
_________________
T. Skin diseases
_______
_________________
U. Surgeries
_______
_________________
V. Other_____________________________________________________________________
Any previous PT? _________ If yes, where? ________________________________________
How did you hear about us? Check all that apply:
MD referral_______ Internet______
Family/Friend_____ Phonebook_____
Other_____