Patient Health History and Information

Transcription

1 Patient Health History and Information Date: Age: Height: Weight: Sex: M F Dominant hand: R L Could you be or are you pregnant: Y N Reason for Therapy: Date of injury/onset of symptoms: / / Please describe how your injury/problem occurred (i.e. fall, activity, work, auto, unknown): Recent surgery? Yes No Date: / / Type: Please list any treatment you have received for this condition (i.e. Therapy, Chiropractor): For this condition have you had any of the following? None X-ray / / MRI / CT scan / / Injection: type: / / Surgery: type: / / Other: / / Using the key below indicate on the body diagrams where your symptoms are located. X=Pain //= Numbness O=Tingling Please rate your pain (0=none, 1=minimal, 10=severe) At present: At worst: At best: Please describe your pain/symptoms Which side are we seeing you for?: Right Left What makes your symptoms worse? (i.e. heat, cold, rest) What makes your symptoms better? (i.e. heat, cold, rest) Please indicate your current limitations due to injury: Laying down Bending Sleeping: Going from sit to stand Work Sitting: Up / Down stairs Driving Walking: Squatting Swallowing Standing: Looking overhead Turning head Reaching: Taking a deep breath Self care / Hygiene Repetitive activities Constant Intermittent Increasing Decreasing Talking / Chewing / Yawning / All (circle one) Staying the same Sharp Dull Aching Burning Weakness Throbbing Other: Home activities Sports / Recreation Other: Since your symptoms began have you had any of the following: Fever / Chills Yes No Unexplained weight change Yes No Nausea / Vomiting Yes No Night sweats / pain Yes No Numbness genital/anal area Yes No Problems with vision / hearing / speech Yes No Dizziness / Fainting Yes No Difficulty with bowel/bladder function Yes No Unexplained weakness Yes No Other: Yes No Headaches Yes No

2 Who referred you to Physical Therapy? Primary Physician: How did you hear about PTOSI Physical Therapy? Physician Friend/relative Website Previous patient Self Coach Other What are your goals for therapy? GENERAL HEALTH HISTORY: Have you had any falls or near falls in the past year? Yes No Rate your overall health: Excellent Good Average Poor Do you exercise? Yes No x/week Do you smoke? Yes No Do you drink caffeinated beverages? Yes No /week Occupation/job title: Self Student Full time Part time Retired Unemployed Living Situation: Alone Spouse Family Others Physical activities at work: Sitting Standing Computer use Phone use Repetitive/Heavy lifting Other: Employer: Current work duty: Full duty Restricted duty Work days missed: QRC (if you have one): Have you or anyone in your immediate (brother, sister, parent, grandparent) family ever been diagnosed with any of the following: Allergies/asthma Self Family No Kidney problems Self Family No Cancer Self Family No Thyroid problems Self Family No High blood pressure Self Family No Epilepsy/dizziness Self Family No Heart trouble/angina Self Family No Tuberculosis Self Family No Diabetes Self Family No Anemia/blood disorder Self Family No Stroke Self Family No Multiple Sclerosis Self Family No Osteoporosis Self Family No Circular/vascular problems Self Family No Osteoarthritis Self Family No Chemical dependency Self Family No Rheumatoid arthritis Self Family No Pace maker/metal implants Self Family No Depression Self Family No AIDS/HIV Self Family No Headaches Self Family No Hepatitis Self Family No Bladder/bowel problems Self Family No Other: Self Family No Over the past 2 weeks, how often have you been bothered by any of the following problems? 1. Little interest in the pleasure of doing things: 0- Not at all 1- Several days 2- More than half the days 3- Nearly every day 2. Feeling down, depressed or hopeless: 0- Not at all 1- Several days 2- More than half the days 3- Nearly every day Are there any other issues/concerns that you think we should know about that may or may not effect your ability to benefit from physical/occupational therapy treatment: Yes No Patient Signature: Date / / Reviewed by Therapist: Date / / MD follow-up: / / None Scheduled With-in 90days of last Medical history completion (date and initial any changes) Medical History reviewed by patient, changes noted and reviewed by therapist. Patient Signature: Date / / Reviewed by Therapist: Date / /

3 Bladder and Bowel Symptom Questionnaire 1. How often do you urinate during the day? times, at night? times. 2. How often do you have a bowel movement? times/day/week? 3. How often do you experience bowel/bladder leakage? Never Less than daily Daily Throughout day Nighttime/Sleep 4. What is the amount of leakage? No leakage Soils pad or underwear Soils outerwear 5. What type of protection do you wear? None Pantiliner Maxipad Specialty product Other How many do you use per day? 6. What causes you to leak? (Check all that apply) Vigorous activity (running, aerobics) Light activity (walking, light house work) Cough/sneeze Walking to the toilet Strong urge to go Intercourse or sexual activity Other 7. How long can you delay the need to urinate? Not at all 1-5 min 5-10 min min 30+min 8. How much fluid do you drink each day? (One glass = 8 oz. or one cup) total glasses of liquid per day # of caffeinated glasses per day # of alcoholic beverages per day 9. Rate your feelings as to the severity of this problem from 0-10, 10 being the worst No Problem Major Problem Additional comments:

4 Bladder Habits 1. Are you unable to stop the flow of urine when on the toilet? 2. Is it difficult to tell when you need to go to the toilet? 3. Do you strain to pass urine? 4. Do you empty your bladder before you experience the urge to urinate? 5. Do you have difficulty completely emptying your bladder? 6. Do you have difficulty initiating the stream of urine? 7. Do you have triggers that make you feel you cannot wait to use the toilet? 8. Do you have pain or burning with urination? 9. Do you have pain or discomfort when you wipe yourself? 10. Do you leak more during, before or after your period? Bowel Habits 1. Are you unable to feel that you need to have a bowel movement or pass gas? 2. Do you strain to have a bowel movement? 3. Do you feel your rectum is not completely empty after a bowel movement? 4. Do you have difficulty initiating a bowel movement? 5. Do you have pain or burning with bowel movements? 6. Do you have a history of hemorrhoids? 7. Have you experienced a change in your bowel habits? If yes, please describe 8. Do you take anything to help you pass your stool? If yes, please list 9. Do you have difficulty holding back gas? Pelvic Floor Symptoms 1. Are you sexually active? 2. Do you have pain with intercourse or penetration? 3. Do you have pain with use of tampons? Additional comments:

5 Ob/Gyn & Urological History: Explain yes response and include dates Painful periods Vaginal dryness Painful penetration Pelvic inflammatory disease Difficult childbirth Unusual discharge Uterine/Rectal/Bladder prolapse Perimenopause Prolapse or falling out feeling Colorectal surgery Prostate or other surgery Pregnancy # Fibroids Vaginal deliveries # Dilation & curettage procedure C-section # Endometriosis Episiotomy/Tears # Cysts Menopause (date of last period) Explain yes responses:

6 DOB: Date: Account Number: CONSENT FOR EVALUATION AND TREATMENT I understand that my physician has referred me to physical therapy for evaluation and treatment of pelvic floor dysfunction, and it may be beneficial for my therapist to perform a muscle assessment of the pelvic floor. Palpation of these muscles is most direct and accessible if done via the vagina and/or rectum. I understand that if I am uncomfortable with the assessment or treatment procedures at any time, I will inform my therapist and the procedure will be discontinued and alternatives will be discussed with me. I understand that I may refuse any part of the treatment plan that I am uncomfortable with. I understand that at any time I may request to have another person present during the evaluation and treatment. I hereby request and consent to the evaluation and treatment to be provided by the physical therapist. Patient Name (please print): Patient Signature: Date: Signature of Parent or Guardian (if applicable): ***If you are pregnant, have infections of any kind, have vaginal dryness, are less than 6 weeks post-partum or post-surgery, have severe pelvic pain, sensitivity to KY jelly, vaginal creams or latex, please inform the therapist prior to pelvic floor assessment.

7 DOB: Date: Account Number: 1. In order to provide optimal care it is important for us to maintain an up-to-date list of all your medications. 2. Please fill out the chart below. **If you already have a complete list of your medications, please bring it and we will make a copy in lieu of completing this form. Allergies/Adverse effects to medications: Name of prescription medication (brand or generic) Dosage Why are you taking this medication? How often do you take it? How do you take it? (by mouth, injection, etc.) Example: Lasix 20 mg. High blood pressure Two times a day By mouth Over the Counter medication or nutritional supplements Dosage Why are you taking this medication? How often do you take it? How do you take it? (by mouth, injection, etc.) Patient Signature: Date: a Patient updated: Date: Therapist reviewed: Date: a Therapist reviewed: Date: