Karen Morgan Physical Therapy
511 E. Magnolia Street #200
Bellingham, WA 98225
Date
First Name
MI
Street
Last Name
Date of Birth
City
State
Sex
Zip
Email Address
Phone
Primary Care Physician
Physician Phone
Right Handed
Height ___’ ___” Weight _____ lbs
Left Handed
Your Primary Race – check only one
Asian
African American
Hispanic/Latino
Living Companions - check only one
Alone
Spouse Only
Spouse & Others
Native American/Alaskan
Children Only
Pacific Islander
Other Relatives
White
Group Setting
Other
Living Environment – check all that apply
Stairs
Handrails
Caregiver
Religious/Cultural Beliefs/Wishes that might affect care?
Insurance Information – Please call your insurance company for the following information
Primary Insurance
Secondary Insurance
Insurer Name
Insurer Name
Insurer Phone #
Contact Name
Insurer Phone #
Contact Name
Subscriber’s Name
Subscriber’s Name
Subscriber’s Relation
Subscriber’s Relation
Subscriber’s Date of Birth
Subscriber’s Date of Birth
Member #
Member #
Group #
Group #
PT Copay Amount
PT Copay Amount
PT CoPay Percent
PT CoPay Percent
Deductible
Paid YTD
Deductible
Paid YTD
PT Annual Visits Cap
PT Visits Used
PT Annual Visits Cap
PT Visits Used
PT Annual Dollars Cap
PT Dollars Used
PT Annual Dollars Cap
PT Dollars Used
Requirements
Prior Authorization
Doctors Written Referral
Requirements
Prior Authorization
Doctors Written Referral
Karen Morgan Physical Therapy
511 E. Magnolia Street #200
Bellingham, WA 98225
Family History: List the relative (Brother, Sister, Mother, Father, Aunt, Uncle, Grandmother, Grandfather) and
condition (Arthritis, Cancer, Diabetes, Heart Disease, Hypertension, Osteoporosis, Psychological, Stroke, Other )
Relative
Condition
Age at Onset
Medical History – previous conditions – check all that apply
Allergies
Arthritis
Blood Disorder
Broken Bone/Fracture
Cancer
Circulation/Vascular
Depression
Developmental/Growth Problems
Diabetes/High Blood Sugar
(F) Endometriosis
Head Injury
Heart Problem
High Blood Pressure
Hypoglycemia/Low Blood Sugar
Infectious Disease (TB, Hepatitis, etc)
Kidney Problems
Lung Problem
(F) Menstrual Problems
Multiple Sclerosis
Muscular Dystrophy
Osteoporosis
Parkinson’s Disease
(F) Pelvic Inflammatory Disease
(F) Pregnancy/Delivery Complications
(M) Prostate Disease
Repeated Infections
Seizures/Epilepsy
Skin Disease
Stroke
Thyroid Problems
Ulcers/Stomach Problems
Other
Surgery History
Date
Type of Surgery
Recent Symptoms – last 12 months – check all that apply
Bowel Problems
Chest Pain
Cough
Coordination Problems
Difficulty Sleeping
Difficulty Swallowing
Difficulty Walking
Dizziness/Blackouts
Fever/Chills/Sweats
Headaches
Hearing Problems
Heart Palpitations
Hoarseness
Joint Pain/Swelling
Loss of Balance
Loss of Appetite
Nausea/Vomiting
Pain at Night
Pregnant
Shortness of Breath
Urinary Problems
Vision Problems
Weakness in Arms/Legs
Weight Gain/Loss
Other
Job Status – check one and fill in occupation
Full Time
Part Time
Homemaker
Occupation :
Student
Retired
Unemployed
Habits: Smoking : Cig Pks/Day _____ Pipes/Day _____ Cigars/Day _____ Stopped Smoking ___________
Drinks: Alcohol Drinks/Day _____ Caffeine Cups/Day _____
Exercise: Primary Type/Sport _____________________________ Min/Day _____ Days/Wk _____
General Health: Excellent
Good
Fair
Poor
Clinical Tests – last 12 months – check all that apply
Angiogram
Arthroscopy
Biopsy
Blood Test
Bone Scan
Bronchoscopy
CT Scan
Doppler Ultrasound Echocardiogram
Electrocardiogram
Electroencephalogram
Electromyogram
Mammogram
MRI
Nerve Conduction Velocity
Pap Smear
Pulmonary Function Test
Spinal Tap
Stool Test
Stress Test
Urine Test
X-rays
Other
Medications you are currently taking - check all that apply
Advil/Aleve
Antacids
Antihistamines
Aspirin
Decongestants
Ibuprofen/Naproxen
Tylenol
Other
Prescription Med Name
Prescription Med Name
Prescription Med Name
Prescription Med Name
Herbal Supplements
Karen Morgan Physical Therapy
511 E. Magnolia Street #200
Bellingham, WA 98225
Referral Physician:
Major Life Changes – last 12 months – new baby, job change, death in the family
Describe the condition for which you are seeking physical therapy:
Date of Onset
Describe the event that led to the condition
If you have had the condition before what did you do for it?
Did it get
better?
(Y/N)
How long
did it last?
How are you taking care of the condition now?
What makes the condition better?
What makes the condition worse?
What meds are you taking for this condition?
Where is your pain located?
What makes the pain better?
Rate the pain intensity
(0=none 10=severe)
What makes the pain worse?
What are your goals for physical therapy?
I have difficulty with – check all that apply
Household Chores
Driving
Shopping
Working
School
Recreational Activities
Sports
Other practitioners treating you for this condition – check all that apply
Acupuncturist
Cardiologist
Chiropractor
Dentist
Internist
Massage Therapist
Naturopath
Neurologist
Obstetrician/Gynecologist
Occupational Therapist
Orthopedist
Osteopath
Pediatrician
Podiatrist
Primary Care Physician
Rheumatologist
Physiatrist
Physical Therapist
Other