PHYSICAL THERAPY HEALTH QUESTOINNAIRE
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- Elaine Cooper
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1 PHYSICAL THERAPY HEALTH QUESTOINNAIRE Welcome to our office. You will be given a complete physical therapy examination of your musculoskeletal system. Other records, such as your medical history and x-rays may also be evaluated. To aid in this evaluation and to plan the best course of treatment for you, it is important to obtain certain information about your dental and medical symptoms. Please bring any previous x-rays you may have. Please answer each question and write freely on the discussion questions. Use the back of the page if you need more room. Thank you for your cooperation and assistance. Name: Date: Please answer each question. 1. Are you in good health? Yes No 2. Date of last physical exam? Yes No 3. Are you now under the care of a physician? Yes No 4. Have you ever had a serious illness or injury? Yes No If yes, please give date and explain. 5. Have you ever been hospitalized? Yes No If yes, please give date and explain. 6. Medications: List medications, prescriptions and nonprescription drugs taken regularly. Please include dosage, frequency, and how long you have taken them. 7. Allergies: List allergies and type of reaction (e.g., penicillin rash)
2 8. Have you ever been treated for any of the following? If yes, give date of treatment or occurrence. YES Date NO Asthma or wheezing Tuberculosis Chronic chest condition Frequent colds, sinus or nose trouble Stomach or duodenal ulcers Persistent or recurrent indigestion Bowel or intestinal trouble Gallbladder stones Liver trouble or jaundice Dysentery or colitis Diabeters or sugar in urine Kidney trouble High blood pressure or hypertension Heart trouble, murmurs, or heart attack Chest pain Shortness of breath Chronic or recurrent eye trouble Chronic or recurrent ear trouble Any birth abnormalities Fatigue Insomnia Rehumatism or arhritis Rheumatic fever Swollen or painful joints Rupture or hernia Skin disease, rash, or acne Fainting spells Stroke Paralysis Epilepsy, seizrues, convultions Varicose veins Piles or hemorrhoids Painful or difficult urination Hypoglycemia Goiter or thyroid tourble High Metabolism Low Metabolism Cancer Anemia Protein, blood, or pus in urine Sexual Problems
3 9. Are you currently being treated, or have been treated by a psychiatrist or psychologist? YES NO 10. Are you on disability or applying for disability? YES NO 11. Are you involved in any litigation? YES NO If yes, please explain the situation PAIN HISTORY 1. Please describe your chief complaint: Please list the date chronologically of all physicians, osteopaths, dentists, physical therapists, chiropractors, hopsitlas, clinics, etc. who have been involved in the problem for which you are seeking treatment. Include phone numbers and addresses where possible. For more space, use back of sheet. 2. What treatment have you had to correct your problem? 3. What degree of success have you had with your previous treatments? 4. Do you have an opinion as to what should be done to solve your problem? 5. When did your symptoms first appear? Have they worsened? 6. If you condition is related to any accident, please describe the event on reverse side of this page. 7. Did symptoms start after any injury to any of the following? Circle all that apply.
4 Jaw Neck Head Back Extremity Sever emotional upset Flu or virus Dental treatment Orthodontic treatment Surgical intervention Digestive problems Car accident YES NO GENERAL FINDINGS 1. Does the pain or discomfort disturb your sleep? 2. Does the pain or discomfort interfere with your daily routine or activities? 3. Do you consider yourself a nervous person? 4. Do you often feel depressed or unhappy? 5. Are you easily tired? 6. Are you easily upset? 7. Have you ever had previous neck, shoulder or back pain? 8. Do you frequently have cold hands or feet? 9. Do your nails break easily? 10. Is your skin dry? 11. Does the cold weather bother you? 12. Does hot weather bother you? 13. Please indicate anything else about yourself that you suspect may be related to your condition. _ 14. Do any of the following daily activities cause you pain or discomfort? Yawning Sitting (How long) Bending forward Chewing Work activities Bending Backword Swallowing Turning head Moving shoulders Singing Turning neck Moving arms Shouting Turning trunk Driving Speaking Standing (How long) Walking Brushing teeth In & out of bed Running Sleeping 15. Indicate the types of sensation that you experience. Infrequent Aching Shooting Superficial Intermittent Dull Throbbing Deep Constant Sharp Tingling Localized Cyclic Burning Numbness Diffused Piercing 16. What is the severity of your pain? (Please circle on that applies) None Worst imaginable 17. When is the pain or dysfunction the worst?
5 Morning Afternoon Evening During sleep Upon awakening After awakening SOCIAL HISTORY Please list and date chronological on the reverse side of this page any change in occupation, residence or relationships in the last ten years. (i.e. death of spouse, separation, death in family, change of financial status, etc.) Please list your hobbies and other activities you participate in: Please list any activities that you use ot do but you are unable to do now: Please list and specify amounts of any vitamins, minerals or supplements that you regularly take. Please describe any regular exercise you do. HEAD/TMJ HISTORY YES NO 1. Does it hurt when you open your mouth wide? 2. Does your jaw make noises so that it bothers you or others? 3. Do you suffer from pain in face, jaw, eyes, throat, neck or temples? Circle all that apply 4. Do you suffer from headaches? 5. Do you grind your teeth in your sleep or has anyone heard you? 6. Are you aware that you clamp or set your teeth? 7. Do you have any of the following symptoms upon awakening? Circle all that apply.
6 Stiff Jaw Sore jaw or teeth Headaches Cracking or locking jaw 8. Does your jaw feel tired after a big meal? 9. Must you chew on one side exclusively If yes, which side? DIGESTIVE HISTORY 1. How long have you had abdominal pain? 2. Do you have more than one pain? YES NO If yes, how many different pains do you have? 3. Where is the worst pain located? 4. How often does the pain occur, and how long does it generally last? 5. Does the pain ever awaken you from sleep? YES NO 6. Is the pain ever so sever that it is unbearable and interferes with your normal daily activities? 7.How would you describe the pain? Cramping, aching, burning, knifelike, or. _ 8. Have you found anything you can do or take to alleviate the pain? YES NO 9.Does eating or drinking make the pain better or worse? 10. Have you identified certain foods that seem to trigger pain or diarrhea? _ 11. Describe your typical pattern of bowel movements and the consistency of feces. (For example, one bowel movement, every three days, which is hard and difficult to pass, or two or three loose, watery bowel movements a day.) 12. Has this pattern remained constant, or has it changed in recent months? _ 13. Is the pain usually relieved after a bowel movement? 14. Do you have any of the following associated symptoms? (Check those that apply.) Bloating Nausea Belching Gas Vomiting 15. Have you lost weight in recent months? If so, how much over what time period? 16. Have you passed blood in your stool or had black, tarry bowel movements? YES NO 17. Have you previously been evaluated for these complaints? If yes, what tests were performed, and what were the results? 18. Comment on the effectiveness or side effects of any previously prescribed medications that you have taken for your complaints 19. Do you smoke? YES NO 20. Do you consume alcohol? YES NO
7 Signature Date NUTRITIONAL HISTORY Do you usually eat: (Check all that apply) Breakfast Lunch Dinner Between meals Before bed For each food item, mark the column that indicates how often you eat that food. (D=Daily, W=Weekly, M=Monthly, N=Never) Nonfat milk Lowfat milk Wholefat milk Dairy products Ice Cream Caffeinated coffee/tea Decaffeinated coffee/tea Herbal tea Refined sugar Add salt to food Highly salted foods White bread Chocolate Pastries/desserts Candy Regular soft drinks Caffeinated soft drinks Decaffeinated soft drinks Diet soft drinks Alcohol Beer 3XD D 3XW W 3XM M N
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