Occupation: Leisure Activities: ALLERGIES Are you latex-sensitive? Y N List any medication(s) you are allergic to:
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1 Hello and thank you for choosing Fusion Physical Therapy as the provider for your current healthcare need(s)! We look forward to working with you to help make your day a little easier! To ensure you receive a complete and thorough evaluation, please provide us with your important background information on the following form. If you do not understand a question, leave it blank and your therapist will assist you. Name: Age: Gender: Patient Characteristics Occupation: Leisure Activities: ALLERGIES Are you latex-sensitive? List any medication(s) you are allergic to: List any other allergies we should know about: Please check ( ) any of the following providers whose care you are under: medical doctor osteopath dentist psychiatrist psychologist Current Physicians & Non-physician providers physical therapist chiropractor other: Date of your last physical examination: Has anyone in your immediate family (parents, brothers, sisters) ever been treated for any of the following? Relevant Alcoholism Family History (chemical dependence) High blood pressure Cancer Inflammatory arthritis Depression Kidney disease Diabetes Stroke Heart Disease 1 P a g e
2 Have you EVER been diagnosed as having any of the following conditions? Arthritic conditions. If Y, what kind: Asthma Blood Clots Cancer. If Y, what kind: _ Chemical dependence (e.g. alcoholism) Circulation problems Depression Diabetes Heart problems. If Y, what kind: Hepatitis High blood pressure Kidney disease. If Y, what kind: Multiple Sclerosis Osteoporosis Stomach ulcers Stroke Thyroid problems. If Y, what kind: _ Tuberculosis Other condition(s): DATE REASON SURGERIES &/or HOSPITALIZATIONS 2 P a g e
3 General Health Screening: o Are you currently pregnant? NA o During the past month have you been feeling down, depressed, or hopeless? o During the past month have you been bothered by having little interest or pleasure in doing things? o Do you ever feel unsafe at home or has anyone hit you or tried to injure you in any way? o Have you ever been threatened, hurt, or made to feel afraid or humiliated by your partner or someone close to you? o On average, how many days per week do you engage in moderate-tostrenuous exercise (like a brisk walk)? _ days. o On average, how many minutes do you exercise at this level? minutes. o How much sleep do you typically get? hours per night. o Do you feel well rested when you wake up? o Is your current condition impacting your sleep? If Y, how so? o How would you rate your sleep quality? Good Fair Poor o Does being sleepy during the day interfere with your daily function? o Do you have difficulty falling asleep? o Do you have difficulty returning to sleep if you wake up in the night? o Do you have difficulty with waking up too early? o Do you snore loudly or frequently? o Has anyone observed you stop breathing while you sleep? o When you try to relax in the evening or sleep at night, do you ever have unpleasant, restless feelings in your legs that can be relieved by walking or movement? o How many caffeinated beverages (coffee or other) do you drink per day? o Do you smoke?. If Y, how many packs per day? For how many years?. If you quit, when? o How many days/week do you drink alcohol?. If 1 drink = 1 beer 3 Por a g1 e glass of wine, how many drinks will you typically have at one sitting?
4 General Health Screening (cont d): Please select your most accurate response to each of the following questions: o Have you experienced a decline in your food intake over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties? severe decline moderate decline no decline o Have you experienced weight loss over the past 3 months? don t know lost more than 6 pounds lost 2-6 pounds no weight loss o How mobile have you been over the past 3 months? chair / bed-bound can get in out of chair/bed, don t go out can go out o Have you suffered psychological stress or acute disease in the past 3 months? yes no o Have you experienced problems with depression, dementia or any other psychological problems over the past 3 months? severe problems mild problems no problems Would you be interested in having a future discussion about your overall health with your therapist? yes ask me again later no Have you been experiencing any NEW, UNUSUAL or ATYPICAL symptoms recently? weight loss/gain nausea/vomiting dizzy/lightheaded fatigue fever/chills/sweats weakness numb/tingling tremors seizures double vision loss of vision eye redness skin rash problems sleeping sexual difficulties night sweats hearing problems recent fall down joint/muscle swelling easy bruising excess bleeding difficulty breathing regular cough arm/leg swelling heart racing difficulty swallowing heartburn constipation/diarrhea problems with bladder &/or bowel control 4 P a g e
5 Medication List Please complete our Medication, Supplements & Remedies form or, if you have your own form, please provide so we can make a copy. BODY DIAGRAM Please mark any area(s) of your body in which you are having ongoing symptoms. Please use 1-2 words to describe each symptom you are experiencing (eg. sharp pain, dull pain, numbness, tingling, pins & needles, etc. 5 P a g e
Thank you for choosing Therapy Works to assist you with your current condition.
Therapy Works Welcome Packet Thank you for choosing Therapy Works to assist you with your current condition. Please fill out the enclosed paperwork and bring back with you to your appointment. Important
Office Location: Media Glen Mills Havertown Date of Evaluation. Last Name, First, Address. City State Zip. Home Phone: ( ) -- Work Phone:( ) -- SS#
Pain Relief and Physical Therapy 203 E Baltimore Pike, Suite 2 101 W. Eagle Road, Suite 1 Media, PA 19063 Havertown, PA 19083 Phone: 610-565-0670 Phone: 610-789-9887 Fax: 610-565-7706 Fax: 610-789-9883
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Address Street Address City State Zip Code. Address Street Address City State Zip Code
Male Initial Visit Intake Form PATIENT INFORMATION Today s Date Last Name Mid Initial First Name Date of Birth Address Home Phone Social Security Number Street Address City State Zip Code Cell Phone E-mail
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