0 = no pain 10 = worst pain ever

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Patient Information Page 2
*REQUIRED MEDICARE INFORMATION
Name: _____________________________Date of Birth _________________
Age: _______________
In Emergency notify: ___________________ Relationship ______________Phone ___________________
Leisure Activities: _____________________________ Job Description: ____________________________
*Medications, Frequency, and Dosage: _______________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
*Weight _________ *Height________
Allergies: _______________ Are You Pregnant? ________ PACEMAKER/DEFIBRILLATOR ___________
Have you ever been diagnosed with any of the following? (Please circle those that apply)
Cancer
Diabetes
Hypoglycemia Hypertension Heart Disease
Allergies
Asthma
Kidney Disease
Hepatitis
Emphysema Liver Disease Chronic Bronchitis Polio
Rheumatic Fever
Reiter’s syndrome
Osteoporosis
Do you suffer from any of the following? (Please circle those that apply)
Chest Pain
Headaches
Shortness of Breath
Ringing in the Ears
Stroke
Osteoarthritis Rheumatoid Arthritis
Ulcers
Pneumonia
Other: __________________________
Kidney Problems
Urinary Problems
Dizziness
Changes in Bowel/Bladder function if so How _______________
Past Medical Problems, surgeries, and hospitalizations:
_________________________________________________________________________________
_________________________________________________________________________________
__________________________
Please note any recent x-rays, CT Scans, MRI or other medical tests taken and their results.
______________________________________________________________________________________________
_____________________________________________________Do you have reports? _____________________
What do you hope to achieve in therapy? ________________________________________________________
______________________________________________________________________________________________
Date of Onset/Exacerbation for this problem today: _______________________________________________
Previous Therapy for this? Yes/No if yes when? _______________________ Where: __________________
Describe the history/cause behind the pain/condition you are here for today:
_________________________________________________________________________________________________
___________________________________________________________________________________________
Describe your pain: (i.e. burning, stabbing, aching,
etc.)_____________________________________________________________________
____________________________________________________________________________________________________________
__________________
Please indicate on the diagram where your pain is located:
0 = no pain 10 = worst pain ever
Highest pain level
Lowest pain level
_____
_____
What activities increase Pain or
exacerbate your Condition?
__________________________________
__________________________________
__________________________________
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