PAIN/MEDICAL QUESTIONNAIRE
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1 87944 CH-3943 (JAN 11) Page 1 of 2 REHABILITATION SERVICES GENERAL INTAKE FORM PAIN/MEDICAL QUESTIONNAIRE (Page 1 of 2) TO BE COMPLETED BY PATIENT OR FAMILY MEMBER ON BEHALF OF PATIENT 1. Do you understand written English? 2. Do you understand spoken English? 3. Do you have visual problems that impair your ability to read? 4. Do you need an interpreter? 5. Do you have a hearing problem? 6. Are you or a family member being harmed or not taken care of? 7. Are there any customs/religious beliefs/rituals/wishes that might affect your care? 8. What is the reason for your visit today? 9. When did this problem begin? 10. Have you seen, or are you currently seeing anyone else for this problem(s): If Yes, who? (Check all that apply) Another Therapist Acupuncturist Cardiologist Chiropractor Dentist ENT Family MD Massage Therapist Neuropsychologist Plastic Surgeon r Physiatrist OB/GYN Orthopaedist Osteopath Pain Specialist Pediatrician Ophthalmologist Rheumatologist Neurologist Podiatrist Dermatologist r Other: 11. Have you ever had this problem(s) before? If Yes, what did you do for it? 12. Did the problem(s) get better? 13. How are you taking care of the problem(s) now? 14. When is your next appointment with the physician who referred you to us? 15. Have you ever been told that you have: (Check all that apply) Allergies r Low Blood Sugar/ Arthritis Hypoglycemia Blood Disorders Liver Problems r Broken Bones/ Lung Problems Fractures Multiple Sclerosis Cerebral Palsy Muscular Dystrophy r Circulation/Vascular Osteoporosis Problems Parkinson s Disease Chemical Dependency Repeated Infections Depression Seizures/Epilepsy r Developmental or Skin Diseases Growth Problems Stroke r Diabetes/High Blood Thyroid Problems Sugar r Ulcers/Stomach Head Injury Problems Heart Problems Mental Health Issues High Blood Pressure Reflux r Infectious Disease r Other: (such as Tuberculosis, Hepatitis) r Kidney Problems 16. List any surgeries that you have had: Surgery: 17. Do you have a shunt? 18. Do you have a pacemaker? 19. Are you pregnant? r Don t Know 20. Have you had any cancer? 21. Do you have a latex allergy? 22. Do you have skin sensitivities or allergies? (i.e., Tape) If Yes, give details: REHABILITATION SERVICES GENERAL INTAKE FORM PAIN/MEDICAL QUESTIONNAIRE (Page 1 of 2)
2 87944 CH-3943 (JAN 11) Page 2 of 2 REHABILITATION SERVICES GENERAL INTAKE FORM PAIN/MEDICAL QUESTIONNAIRE (Page 2 of 2) 23. Within the past year, have you had any of the following? (Check all that apply.) Bowel Problems Hoarseness Chest Pain Joint Pain or Swelling Coordination Problem Loss of Appetite Cough Loss of Balance Difficulty Sleeping Nausea/Vomiting Difficulty Swallowing Pain at Night Difficulty Walking Shortness of Breath Dizziness or Blackouts Urinary Problems Fever/Chills/Sweats Vision Problems r Headaches r Weakness in Arms/Legs Hearing Problems Open Wounds Heart Palpitations Loss of Sensation r Weight Loss/Gain r Other: How much? 24. List all current prescriptions, over-the-counter medications and herbal supplements you are taking: (Use back if needed) 25. Do you have any difficulty taking medications as prescribed? If Yes, give details: 26. List any drug or food allergies: (Sulfa, shellfish, lodine, IV dye, etc.) 27. Employment: r Working Full-Time Occupation: Are you off Work: r Working Part-Time List any restrictions given to you by your Doctor: 28. With whom do you live? (Check all that apply) Alone Partner/Spouse Child(ren) Parent(s) Foster Care r Grandparent(s) r Other: 29. Have you had any major life changes during the past year that would affect your care: If Yes, please explain: Testing: 30. Check all diagnostic testing already performed for this diagnosis, if any: Arterial Studies MRI Audiogram Tissue Biopsy Bone Scan Venous Doppler CT Scan Wound Cultures EMG X-Rays r ENG r Other: Patient/Family Education: 31. If home instructions are prescribed, how do you learn them best? (Check all that apply) Printed Material Verbal Instructions Demonstration Pictures r Trial and Error r Other: Pain: 32. Do you have pain? If Yes, where? Homemaker r Retired Student r Unemployed r On Disability? As of what date? REHABILITATION SERVICES GENERAL INTAKE FORM PAIN/MEDICAL QUESTIONNAIRE (Page 2 of 2)
3 REGISTRATION REHABILITATION SERVICES PATIENT INFORMATION Patient Name Date of Birth Social Security # - - Home Address City State Zip Code Home Phone Cell Phone Marital Status (please circle) Single Married Divorced Widowed Patient Employer Name Full or Part Time Work Phone Address Person Responsible for payment, if not patient: Name Date of Birth Patient Insurance Policy # Was this an accident? (please circle) YES NO If yes, please complete the following: Date of Accident Time of Accident Location of Accident Emergency Contact Name Relation Date of Birth Home Phone Cell Phone
4 87937 CH-3935 (FEB 11) Page 3 of 3 REHABILITATION SERVICES (SUPPLEMENTAL) OCCUPATIONAL THERAPY INTAKE FORM ADULT (Page 3 of 3) TO BE COMPLETED BY PATIENT OR FAMILY MEMBER ON BEHALF OF PATIENT 1. Do you have any adaptive equipment? (i.e., sock aid, bedside commode, grab bars, splints, etc.) 2. PLEASE CIRCLE YOUR CURRENT ABILITY TO PERFORM THE FOLLOWING TASKS USING THIS SCALE: 0 = No Difficulty 2 = Very Difficult/Moderate Assist 1 = Somewhat Difficult/Minimal Assist 3 = Unable to Perform/Maximum Assist N/A = Does Not Apply Dressing Upper Extremity: N/A Comments: Lower Extremity: N/A Comments: Small Clothing Fasteners: N/A Comments: Bathing Upper Extremity: N/A Comments: Lower Extremity: N/A Comments: Feeding Use (grip) Utensils: N/A Comments: Cut Food: N/A Comments: Deliver to Mouth: N/A Comments: Fine Motor Skills Pencil Grasp: N/A Comments: Leisure Activity: N/A Comments: 3. Describe any difficulties you may have with: Lifting: Carrying: Pushing/Pulling: Filing: Writing/Typing: 4. Are you currently having pain? If Yes, please circle your pain level: No Pain = = Extreme Pain Location of Pain: Patient/Guardian Signature: Reviewed By/Therapist Signature: REHABILITATION SERVICES (SUPPLEMENTAL) OT ADULT INTAKE FORM (Page 3 of 3)
5 Thank you for choosing our Rehabilitation Services. To help us better serve you: GENERAL POLICY Return appointments are scheduled for minutes. To allow optimal treatment time, please arrive 5-10 minutes before your scheduled appointment to change clothes, use the bathroom, etc. If you arrive 15 minutes late for a scheduled appointment, you may have to: 1. Wait to be seen by your therapist, 2. Receive an abbreviated treatment, 3. Be seen by another therapist, or 4. Reschedule your appointment. Allow plenty of travel and parking time. If you are receiving Physical or Occupational therapy, please wear or bring appropriate clothing for the type of treatment you are receiving. Patient gowns are provided. CANCELLATION 24 hour notification is requested to cancel an appointment. Please call. If you miss an appointment, please call to confirm your next appointment time or to reschedule. Your consistent attendance and participation is imperative to your progress. Therefore, if the recommended plan of care is not followed and/or you are not making progress in your treatment plan, you will be discharged and your physician notified. If this occurs, a new referral for therapy will be necessary to set up a new therapy schedule. ILLNESS Appointments should be cancelled if the patient has a fever of 100 degrees or above, vomited, or has been exposed to or diagnosed with an illness in the past 24 hours. If you have any questions about your care, please discuss with your therapist. We want to assist you with your rehabilitation. A supervisor may be contacted if you have further concerns. BILLING If you have questions regarding the billing of our service, please call Patient Financial Services General Information at (317) or (800) Indiana only. If you need to obtain a copy of your medical records, contact Health Information Management (Medical Records) at or fax your request to To find out about insurance coverage for therapy services, please contact your insurance company. I have read and agree to follow the above policy. Patient Signature Date
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Southern Oregon Physical Therapy Associates, Inc. 924 S. Riverside Ave. Medford OR 97501 541.773.7678 Fax 541.773.5517 Email: sopta@integra.net website: southernoregonphysicaltherapy.com Health History-1
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Don Wheeler LMT. Joleen Kolk LMT Neuromuscular Therapy Corrective Massage Therapy
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Welcome to Moving Body Chiropractic! We re glad you re here. Whether you re looking to work on a specific problem or just feel great, this form is the start to your wellness journey! Please take the time
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