Physiotherapy Assessment (Condition > 4 weeks)
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- Sheryl Lewis
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1 Greg de Jong: Physiotherapist & Nutritionist 35 Beach Street Merimbula NSW 2548 Ph: Fax: Physiotherapy Assessment (Condition > 4 weeks) By accurately and in detail completing this questionnaire I can make more efficient use of your therapy session. Thank you for your time in filling out the new patient questionnaire. You can leave out any questions if you wish, or write more if you feel there is any other relevant information you need add. Name: DOB Address Phone: If you have a smart phone is it Apple/Android/Microsoft based? (Knowing this helps with providing information on Apps that may help with your Condition) Private Health Fund: No: Medicare No. (if on a Care Plan) Height: Weight Today s Date: Please provide a brief description of you main reason for this appointment:
2 On the diagram below mark where you experience your pain with a brief description of its nature (sharp, burning, dull, ache) and a score out of ten (0 is no pain up to 10 as worst pain imaginable?) If you have different areas of pain identify them separately. Mark any areas of pins and needles or numbness you experience? List when you experience each of the above symptoms. If there are 2 or more different symptoms identify when each occurs separately. Symptom Activities Do you experience any of the following (circle)? Dizziness Visual Problems Slurred Speech Legs collapsing Problems toileting Pins/Needles in groin Uncontrollable Night Pain Difficulty Swallowing Nausea/Vomiting
3 When and how did this condition begin? How and when has the condition progressed? What treatments have you tried and how have they effected your condition? What do you do for work/housework? How does this condition affect your work? Do your exercise/play any sports? How does this condition affect your exercise/sports? What hobbies/activities do you enjoy?
4 What can you do to relieve your pain including positions, exercise, heat/cold, lotions and potions and medications? Do you smoke and if so, how many/per day? Do you drink alcohol and if so, how many/per day? How many serves of caffeine (coffee, energy drinks) per day Do you have any issues of Yes/No: weight loss or gain, especially if this injury has persisted? Amount of weight loss/gain? Over how long? What are your present weight goals, if any? How many hours sleep do you get per day? When do you go to sleep and wake up normally? Do you follow a regular pattern of sleep or is it chaotic? Do you have problems with sleep and if so, what are they? What is your usual sleep position? How do you change you sleep position to control the pain? How many pillows do you use?
5 On average how long do you sit per day? On average how long do you stand per day? How long are you physically active without specifically exercising? Describe a normal exercise/sport week? Are you satisfied with the amount of exercise you are doing? If not, what would you like to change? Do you do any Relaxation/ Creative Visualisation/Meditation activities in order to improve your condition or life in general? What Pleasure Activities do you enjoy and what are you Passionate about in life? Have these been effected by your condition? Is there any other way in which this condition has changed your life that you may wish to discuss and address with treatment (e.g. family relationships etc)?
6 Have you been Stressed, Anxious or Depressed in the last week (circle which if Yes)? Have you been Stressed, Anxious or Depressed in the last 6 months (circle which if Yes)? Are you Stressed, Anxious or Depressed more often than not? (circle which if Yes)? If you are Stressed, Anxious or Depressed what percentage relates to this condition (mark on line)? None 50% All Circle any Medical Conditions that you have or Box Medical Condition where there is a Family History? Heart Disease High Blood Pressure Low Blood Pressure Diabetes Asthma COPD Chronic Fatigue Fibromyalgia Cancer Epilepsy Depression Anxiety Osteoarthritis Rheumatoid Arthritis PMS Menopause Ankyl. Spondylitis TMJ (Jaw) Problems Hyperthyroid SLE Hypothyroid Dementia Alzhiemers Dis. MS Osteoporosis Osteopenia Mental Health Incontinence Irritable Bowel IBD Other Gastro (List) Liver Disease Psoriasis Eczema Lymphedema Endometriosis Migraines Headaches Any Other Medical Condition/Surgery? Do you have any current illness such as cough, cold or flu? Yes/No Is there any possibility you may be pregnant? Yes/No List your Current Medication including Nutritional/Herbal Supplements?
7 In Summary, what treatment approaches do you consider are relevant to your condition? Believe will Help Willing to Try Massage/Manipulation Yes No Yes No Exercise and Stretches Yes No Yes No Postural Advice appropriate Yes No Yes No to home, work and sport. SCENAR Yes No Yes No Nutritional Supplementation Yes No Yes No Weight Loss Yes No Yes No Learning Appropriate Yes No Yes No Relaxation and Breathing Help with Sleep Yes No Yes No Stress Management Yes No Yes No Other Lifestyle Changes Yes No Yes No Any ideas of your own you wish to mention or explore? Are you prone to fainting or have any fears about any treatment that you may receive (including a fear of needles)? Do you belong to a local pool or gymnasium and if so, which? What equipment at home do you have access to exercise? And finally, and most importantly, write down in detail what will be the most motivating factors in improving your condition and helping you commit to improving this condition?
8 If you use Nutritional Supplements or would consider using Nutritional Supplements for your Condition complete the following; otherwise you may leave this section. Nurtitional Supplements Questionnaire (Tick Box for Yes) Do your regularly miss breakfast? Are you a Vegetarian? Have you been diagnosed with Fibromyalgia? Do you believe you have Chronic Fatigue Syndrome? Do you serve more than 3 serves of Fish/week Do you find swelling or inflammation persists when you are injured? Do you get frequent infections? Do you avoid frequent sun exposure? Is your pain unrelated to posture of movement? Do you get pain in the front of your thighs? Do you get muscle spasms and tightness? Do you get eyelid twitches? Do you crave chocolate? Do you get heart palpitations in the absence of Cardiac Disease? Do you lack energy? Do you feel emotionally exhausted or irritable? Do you nod off during the day? Can you get overly emotional? Do you crave salt? Do you get lightheaded or dizzy? Do you see spots in front of your eyes? Do you avoid red meat? Have you ever been anaemic? If female, does you pain change with your cycles? Do you feel cold much of the time? Have you slowly gained weight over the last few years? Have you noticed a thinning of your hair and eye brows? Do you find it hard to get started in the morning? Is your libido lower than you would like?
9 Do you experience any of the following Gastrointestinal Symptoms (circle): Nausea Flatulence Diarrhea Constipation Pain in Stomach Pain with Bowels Movements Reflux Difficult Digestion Undigested Food in Stools Burping Bloating
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Personal &Work Information Date: Patient Name: Age: Birth Date: / / Preferred Name: Gender: Home Phone: Address: Mobile Phone: City: State: Zip: Occupation: Employer: Work Phone: Email: Emergency Contact:
Consultation Intake Form. Name: Age: Sex: M F T Address: Phone: (day) (evening) Birth date: Present physical complaints:
Consultation Intake Form Date: Name: Age: Sex: M F T Address: Phone: (day) (evening) e-mail: Birth date: What would you like help with at this time? Present physical complaints: Onset and length of symptoms:
Brisbin Family Chiropractic
Information reviewed with patient: Dr. Initials Today s Date Brisbin Family Chiropractic Name: Sex: Male Female Address: City: Postal Code: Home Ph# Work# Ext# Cell# Preferred number (circle one) Home
New Patient Information
Personal Information Last Name First Name Middle Initial Address: Street Unit # City Province Postal Code Date of Birth (Day/Month/Year) Home Phone # Work Phone # Cell Phone # May the clinic leave you
New Patient Pain Evaluation
New Patient Pain Evaluation Name: Date: Using the following symbols, mark the areas of the body diagrams which are affected by your pain: \\ = Stabbing * = Electrical X = Aching N = Numbness 0 = Dull S
Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR
New Patient Intake Bridges Family Wellness Intake Form Full Name: * What is your birthdate? MM/DD/YYYY * What is your gender identity? * Home address: * Cell Phone * Other Phone number(s): Emergency Contact
Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?
CLAYTON PARK CHIROPRACTIC CENTRE INC. Suite 11-117 Kearney Lake Road Halifax, Nova Scotia B3M 4N9 (902) 443-5669 phone (902) 443-9419 fax info@claytonparkchiro.ca For Office Use Only: Bilaterals L R PERSONAL
reasons for visit factors of complaint Date: Work comp injury Automobile accident Other injury
Date: LAST NAME FIRST NAME DATE OF BIRTH CURRENT AGE PRIMARY CARE PHYSICIAN PHONE NUMBER REFERRING PHYSICIAN PHONE NUMBER reasons for visit Work comp injury Automobile accident Other injury PRIMARY REASON
CHIROPRACTIC INTAKE FORM
3885 Duke of York Blvd., Suite C211, Mississauga, ON L5B0E4 T: (905)276-6800 F: (905)276-6802 www.naturawellnessclinic.com CHIROPRACTIC INTAKE FORM DATE: PATIENT INFORMATION Name Sex: M/F Age Date of Birth
Joseph S. Weiner, MD, PC Patient History Form
Date: / / NAME: Last First M. I. Age: Sex: q F q M Birthdate: / / What specific questions or goals do you have for this appointment? Please list the names of other clinicians you have seen for this problem:
NEW PATIENT REGISTRATION PLEASE COMPLETE ALL ITEMS ON EACH PAGE. Name (Last, First, M.I.) Address. City State Zip Code. Phone ( ) Work ( ) Cell ( )
NEW PATIENT REGISTRATION PLEASE COMPLETE ALL ITEMS ON EACH PAGE Date Name (Last, First, M.I.) Address City State Zip Code Phone ( ) Work ( ) Cell ( ) Date of Birth Age Marital Status SSN Employer Employer
PULMONARY MEDICINE PATIENT QUESTIONNAIRE
PULMONARY MEDICINE PATIENT QUESTIONNAIRE Date Name DOB Age Referring Physician What problem brings you to see us today? Have you had any of the following? (Any left blank will be reported in your medical
Today s Date: Date of Birth: Age: Height: Weight: Who Referred: If not referred, how did you choose this office? Why are you seeing the doctor today?
Name: Today s Date: Date of Birth: Age: Height: Weight: PCP: Who Referred: If not referred, how did you choose this office? Why are you seeing the doctor today? Please list major complaint(s) and describe