Patient History. 6. Rate the severity of this problem from 0-10 /10 7. Describe previous treatment/exercises
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1 Patient History OUTPATIENT PHYSICAL THERAPY Name Age Date Best phone number to reach you: check if you prefer to be reached by 1. Describe the current problem that brought you here 2. When did your problem first begin? months/years ago 3. Was your first episode of the problem related to a specific incident? Yes/No If yes, please describe the incident and specify the date 4. Since that time is it: staying the same getting worse getting better Why or how? 5. If pain is present, rate pain on a 0-10 scale, 0 being no problem and 10 being the worst. /10. Describe the nature of the pain (sharp, dull, shooting, achy, constant, intermittent, etc.) 5a. How has your pain affected your ability to function day to day? Has the pain affected your daily activities, work, relationships, sleep or sexual functioning? 6. Rate the severity of this problem from 0-10 /10 7. Describe previous treatment/exercises 8. Activities/events that cause or aggravate your symptoms. Check/circle all that apply. Sitting longer than minutes With coughing/sneezing/straining Walking longer than minutes With laughing/yelling Standing longer than minutes With lifting/bending Changing positions (i.e. sit to stand) With cold weather Light activity (light housework) With triggers (running water, key in door, etc.) Vigorous activity/exercise (running/weight lifting/jumping) With nervousness/anxiety Sexual activity No activity affects the problem Other; please list 9. What relieves your symptoms? 10. How has your lifestyle/quality of life been altered/changed because of this problem? Physical activity, specify Social activities, specify Diet/Fluid Intake, specify Work, specify Other, specify 11. What are your treatment goals/concerns?
2 Since the onset of your current symptoms, have you had: Y/N Fever/Chills Y/N Malaise (Unexplained tiredness) Y/N Unexplained weight change Y/N Unexplained muscle weakness Y/N Dizziness or fainting Y/N Night pain/sweats Y/N Change in bowel or bladder functions Y/N Numbness/Tingling Y/N Other; please describe Health History: Date of Last Physical Exam Tests performed General Health: Excellent Good Average Fair Poor Occupation Hours/week On disability or leave? Activity Restrictions? Mental Health: Current level of stress High Med Low Current psych Therapy? Y/N Activity/Exercise: None 1-2 days/week 3-4 days/week 5+ days/week Describe Have you ever had any of the following conditions or Diagnoses? Circle all that apply/ Describe Cancer Stroke Emphysema/chronic bronchitis Heart problems Epilepsy/seizures Asthma High Blood Pressure Multiple Sclerosis Ankle swelling Head Injury Latex sensitivity Anemia Osteoporosis Hypothyroid/ Hyperthyroid Low Back Pain Chronic Fatigue Syndrome Headaches Sacroiliac/Tailbone Pain Fibromyalgia Diabetes Alcoholism/Drug Problem Arthritic conditions Kidney Disease Childhood bladder problems Stress fracture Irritable Bowel Syndrome Depression Rheumatoid Arthritis Hepatitis HIV/AIDS Anorexia/Bulimia Joint Replacement Sexually Transmitted Disease Smoking History Bone Fracture Physical or Sexual Abuse Vision/eye problems Sports Injury Raynaud s (cold hands and feet) Hearing loss/problems TMJD/neck pain Pelvic Pain Describe Surgical/Procedure History Y/N Surgery for your back/spine Y/N Surgery for your bladder/prostate Y/N Surgery for your brain Y/N Surgery for your bones/joints Y/N Surgery for your female organs Y/N Surgery for your abdominal organs If Yes please Describe; Other Surgery
3 OB/GYN History (Females only) Y/N Child Birth vaginal deliveries # Y/N Vaginal Dryness Y/N Episiotomy # Y/N Painful periods Y/N C-Sections # Y/N Menopause- When? Y/N Difficult childbirth # Y/N Painful vaginal penetration Y/N Prolapse or organ falling out Y/N Pelvic Pain If yes please describe Males Only Y/N Prostate disorders Y/N Erectile dysfunction Y/N Shy Bladder Y/N Painful ejaculation Y/N Pelvic Pain If yes please describe Medications- Pills, injections, Patch Dosage Reason for taking Over the Counter- Vitamins Etc. Dosage Reason for taking Allergies
4 Pelvic Symptom Questionnaire Bladder / Bowel Habits / Problems Y/N Trouble initiating urine stream Y/N Blood in urine/stool Y/N Urinary intermittent / slow stream Y/N Painful urination Y/N Trouble emptying bladder Y/N Trouble feeling bladder urge/fullness Y/N Difficulty stopping the urine stream Y/N Current Laxative use Y/N Trouble emptying bladder completely Y/N Trouble feeling bowel/urge/fullness Y/N Straining or pushing to empty bladder Y/N Constipation/ straining Y/N Dribbling after urination Y/N Trouble holding back gas/feces Y/N Constant urine leakage Y/N Recurrent bladder infections Other/Describe 1. Frequency of urination: awake hours times per day, Sleep hours times per night 2. When you have a normal urge to urinate, how long can you delay before you have to go to the bathroom? minutes, hours, not at all 3. Stream: (please circle) Weak Normal Spray Start and Stop 4. Frequency of bowl movements times per day, times per week, or. 5. When you have the urge to have a bowel movement, how long can you delay before you have to go to the toilet? minutes, hours, not at all 6. If constipation is present describe management techniques 7. Average fluid intake (one glass is 8 oz or one cup) glasses per day Of this total how many glasses are caffeinated? glasses per day 8. Rate a feeling of organ falling out / prolapse or pelvic heaviness/ pressure: None present Times per month (specify if related to activity or your period) With standing for minutes or hours With exertion or straining Other Skip questions if no leakage/ Incontinence 9a. Bladder leakage number of episodes 9b. Bowel Leakage- number of episodes Times per day Times per day Times per week Times per week Times per month Times per month Only with physical exertion/cough Only with physical exertion/cough
5 10a. On average, How much urine do you leak? 10b. How much stool do you lose? Just a few drops Wets underwear Wets outerwear Wets the floor stool straining small amount in underwear complete emptying 12. What form of protection do you wear ( please complete only one) None Minimal protection (tissue paper/papertowel/pantishields) Moderate protection (absorbent product, maxi pad) Maximum protection (specialty product/ diaper) Other On average, how many pad/protection changes are required in 24 hours? # of pads
Name DOB Age Date Address Phone
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New Patient Specialty Intake Form Department of Surgery
This form contains questions specific to the Department of Surgery. If you are new to Baylor College of Medicine and have not been seen in any of our offices, please be sure to complete our New Patient
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CompassionMassage.com. Client Intake Form
Name: Phone: ( CompassionMassage.com Client Intake Form ) E-Mail: Address: _ City: State: Zip: Date of Birth: Occupation: Referred by: In case of emergency: Phone: ( Chiropractor: ) General & Medical Information: