(WE WILL USE ONLY IF WE CAN T REACH YOU ANY OTHER WAY)

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Malcolm Hunt
6 years ago
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1 (WE WILL USE ONLY IF WE CAN T REACH YOU ANY OTHER WAY)

2 BALANCED BODY PHYSICAL THERAPY AND PILATES Client Health Questionnaire Part I Name Date Male ( ) Female ( ) D.O.B. Age Cultural Heritage (Optional) Height Weight Has your height or weight changed in recent months/years? If you have any special needs to be considered prior to or during treatment or training, please describe below: Overall physical condition: Poor Fair Good Excellent Smoker? yes o no o Major life changes in past year: (new job, baby, death in family, divorce, child leaving home, retirement) Health habits: Exercise beyond normal daily activities and chores? No o Yes o Describe the exercise, including how often, how long Medical History: Check or circle those that apply to you now or in the past. Asthma Emphysema/COPD Congestive Heart Failure Hypertension Angina Mitral Valve Prolapse Atrial Fibrillation Other Arrhythmia Pacemaker Other Heart Problems Aneurysm Blood Clots/Phlebitis Stroke/TIA Other Circulation Disorders Seizures/Epilepsy Essential Tremor Headaches/Migraines Parkinson s Other Neurological Disorders Thyroid Problems Diabetes Cancer Type Chemotherapy Blood Disorders Anemia Neutropenia Kidney/Adrenal Disorders Dialysis Urinary/Bladder Control Problems Organ Transplant Autoimmune Disorder Immune Disorder Crohn s Disease Eating Disorder Gastric Bypass Ulcerative Colitis Other Digestive Disease Psoriasis Impetigo Poison Ivy/Oak Eczema Other Rashes or Skin Problems Depression Anxiety Bipolar Disorder Other Psych/Emotional Problem Chronic Pain or other Pain Syndromes Vision Problems Hearing Problems Have you ever had, have you recently been exposed to, or currently have: Chicken Pox Measles Encephalitis Polio Herpes Shingles Hepatitis B Hepatitis C Hepatitis A TB or positive TB skin test HIV/AIDS Flu Pertussis (whooping cough) Have you received any of the following immunizations/ when? Flu (annual) Tetanus/Diptheria (every 10 years) Chicken Pox or new Shingles vaccine Hepatitis B Pneumococcal Vaccine Explain any problems you have checked above: Do you take any of the following types of Medications: Anti-Rejection Chemo Steroids Blood-thinners Rheumatoid Arthritis Drugs? Please describe Revised 06/17/09

3 Check any current symptoms: Chest Pain Shortness of Breath Heart Palpitations Fatigue Ankle Swelling Dizziness Coordination Problems Loss of Balance Difficulty Walking Numbness/Tingling Weakness Arms Legs Abdominal Pain Fever/Night Sweats Difficulty Sleeping Cough Hoarseness Difficulty Swallowing Muscle Pain? Sprain Joint Pain Other pain? Limited Movement Night Pain Orthopedic/Neuromuscular Disorders Osteoarthritis Rhematoid Arthritis Tendonitis Bursitis Shoulder/Rotator Cuff Back Problems Carpal Tunnel Syndrome Sciatic Nerve Pain Peripheral Neuropathy Spinal Fusion Vertebroplasty Spinal Stenosis Scoliosis Knee Problems Knee Replacement Hip Problems Hip Replacement Fractured Hip Neck Injury Other Fractures Sprains/Strains Spondylolisthesis Fibromyalgia Osteopenia Osteoporosis Stroke Head Injury Spinal Cord Injury/ Paralysis Parkinson s Multiple Sclerosis Post Polio Syndrome Other Tell us about any of the above neuromuscular and orthopedic problems. List and give approximate year of any injuries, treatments, surgery, hospitalizations, rehab, medication or physical therapy you received: _List current medications: For Women Only: Are you pregnant? Date of last delivery? # of pregnancies # of vaginal deliveries # of C-sections? perimenopausal? menopausal? Within the past year, have you had any of the following medical tests? (check all that apply) o Angiogram o Bronchoscopy o Myelogram o MRI o Pulmonary Function Tests o Nerve Conduction Velocity o Biopsy (describe) o CT Scan o Electromyogram o Blood Tests o EKG o Arthroscopy o Bone Scan o Cardiac Stress Test o EEG o Bone Density Test o Urine Flow Studies o Cystoscopy o Pap Smear o Mammogram If other than routine test, please explain: Is there any health-related reason why you should not participate in an exercise program? What would you like to get out of our physical therapy or wellness program?

4 BALANCED BODY PHYSICAL THERAPY AND PILATES NAME: Client Health Questionnaire PART II What is your primary problem? When/how did it begin? Have you had this problem before? If so, when? What did you do for it? Did the problem(s) get better? How long did it last? What treatments/diagnostic tests have you received for this problem? None Surgery injections Splint/Brace X-rays MRI CT Scan Chiropractic Care Massage Therapy Physical Therapy Medications (prescription and nonprescription) Other How are you managing the problem now? What activities are you not able to do that you could do before the problem (be as specific as you can.) (Example: unable to reach above your head.) What makes the problem worse? What makes the problem better? When are your symptoms most severe? AM PM Consistent all day Since your problem began is the pain: Increased Decreased Not Changing Constant Intermittent Rate your pain with 0 being no pain and 10 being the worst pain: Pain now Best day Worst day Do you have any other significant problems? Your goal in therapy: What concerns you most? What do you hope to gain from this program? Revised 06/17/09

5 Using the following pictures, indicate where your pain is located. Using these symbols describe your type of pain: Numbness === Ache ^^^ Pins/needles 0000 Stabbing ///// Burning XXXX Cramping ++++ Sharp **** Right Left Left Right Are your symptoms affecting your ability to work or otherwise be active If so, how? Current Limitations: (check all that apply): o Difficulty with movement o Getting in/out of bed or up/down from a chair o Changing positions in bed o Difficulty with grooming and bathing o Walking: o level o stairs o ramps o uneven terrain o Difficulty with home management (household chores, yard work, driving, shopping): o Difficulty with community and work activities (work, school, play, recreation): Thank you for taking the time to provide this information. Balanced Body Staff

6 Optimal Instrument Patient s Name DATE Instructions: Please circle the level of you have for each activity today. without any with little with moderate with much Unable to do Not applicable 1. Lying flat Rolling over Moving-lying to sitting Sitting Squatting Bending/stooping Balancing Kneeling Walking-short distance Walking-long distance Walking-outdoors Climbing stairs Hopping Jumping Running Pushing Pulling Reaching Grasping Lifting Carrying Thinking about all of the activities you would like to do, please mark an X at the point on the line that best describes your overall level of with these activities today. I have extreme doing any of the activities that I would like to do. I have no doing any of the activities that I would like to do. 23. From the above list, choose the 3 activities you would most like to be able to do without any (for example, if you would like to be able to climb stairs, kneel, and hop without any, you would choose: ) For Therapist Use: Total Score - # of questions answered 84 (for 21); 80 (for 20); 76 (for 19); 72 (for 18) = % disability P.T.

7 Patient Name: Prescription Medication Medication List Over the Counter Medications that you regularly take (baby aspirin, ibuprofen, Tylenol, antihistamines, medication for reflux, etc.): Vitamins, Nutritional Supplements, Herbal Products, Probiotics: 1/5/15

Primary Care Physician: Have you had physical therapy during this calendar year? Yes No

Primary Care Physician: Have you had physical therapy during this calendar year? Yes No Name: Date of Birth: Primary Care Physician: Referring Physician: Have you had physical therapy during this calendar year? Yes No Have you had occupational therapy during this calendar year? Yes No If