Forms

Please answer these questions and fill out this form prior to your first appointment.

Name

First Name

Last Name

Today's date

Address

City/State/ZIP

Phone #

Date of Birth

Occupation

Employer

Emergency Contact

Name and phone #

Primary Care Physician

How did you hear about our practice?

Whom can we thank for referring you to our practice?

What is the primary problem that brings you in today?

Secondary concerns/problems?

As a result, I am now having difficulties with:

Are you currently experiencing pain?

When did your symptoms begin? Date:

Please rate your pain in the last 24-72 hours (at worst)

Using the 0-10 scale where 0 is no pain and 10 is the worst possible pain

Please rate your pain in the last 24-72 hours (at best)

At what time of day are your symptoms the worst?

At what time of day are your symptoms the best?

What activities increase your pain?

What activities decrease your pain?

What other types of treatment have you had for this problem?

Massage

Bodywork

Physical Therapy

Myofascial Release

Chiropractic

Other

List all medical conditions

List past medical history and dates of occurrence. Include surgeries, accidents and other traumas

List ALL medications which you are currently taking, the condition for which you are using them, the dose, and their effectiveness. (Include supplements, herbal and homeopathic remedies)

Is there a chance you may be pregnant at this time?

Do you engage in regular exercise? If yes, what type and how often?

Are you able to exercise now?

In general, your lifestyle is:

1 = Active, 3 = Average, 5 = Inactive

List all the Tasks/Activities that you have difficulty performing

e.g. sitting, dressing, walking, playing

Patient Goals: please list the activities that you would like to be able to do as a result of therapy

List Task/Activity, Duration/How Often, and By When

Forms

Be Kind to Your PT... She Knows Where It Hurts!