Page 1 of 8 Date: Patient Account #: Patient Name: Insurance: Date of Birth: History of current condition 1. Which of the following best describes how your injurt occurred? (if your injury is post-surgical please indicate as per original injury lifting dental appointment a fall degenerative process an incident at work unkwn overuse (cumulative trama) during recreation/sports MVA (car accident) State accident occurred other Please indicate the date your symptoms began? (please indicate specific date) Surgery date (if applicable) 2. Nature of primary complaint pain numbness/tingling sharp dull throbbing aching burning intermittent constant weakness other Print this form and mark with a pen using the key below indicate on the body diagrams where your symptoms are located. X = Pain O = Tingling // = Numbness Check the boxes indicating your pain at its lowest and highest levels. 0 1 2 3 4 5 6 7 8 9 10
Page 2 of 8 3. Was the onset on this episode gradual or sudden? (check one) gradual sudden flare up If this is a flare up: original date of onset Number of prior episodes Frequency 4. Since onset are your symptoms getting: (check one) better worse t changing 5. What relieves (R) / aggravates (A) your symptoms sitting rest massage heat standing medication cold walking thing stretching exercise lying down wearing a splint/brace coughing/sneezing other 6. As the day progresses do your symptoms: (check one) increase decrease stay the same 7. Does pain wake you at night? if the pain wakes you up at night, is it present while lying still when changing positions both
Page 3 of 8 8. In what position do you sleep? (check all that apply) sitting rest massage heat standing medication other 9. Do you have pain/stiffness getting out of bed in the morning? 10. Since your symptoms began have you had (check all that apply): fever / chills / nausea / vomiting unexplained weight change any numbness in gential/anal area night sweats / pain numbness / tingling / burning problems with vision / hearing / speech dizziness / fainting any difficulty with bladder / bowel function weakness headaches ne other 11. Current limitations (check all that apply): ne looking overhead going from sit to stand talking swallowing lying down taking a deep breath chewing bending up/down stairs yawning squatting sitting reaching standing walking self care/hygene home management activities repetitive activities sports / recreation other
Page 4 of 8 12. Treatments previously received for this condition? (check all that apply) medication biofeedback/tens Chiropractic TENS unit Physical therapy injection/acupuncture massage casting/immobilization bracing/taping hospitalization surgery (date) other 13. Please check/list any other health care providers you are currently seeing for this condition: ne Podiatrist dentist Physical therapist Chiropractor MD 14. Please check if you have had any of the following? ne EMG CT scan / MRI x-rays other General Health Age: Height: Weight: Dominant Hand? Right Left How would you rate your overall health? excellent good average fair poor
Page 5 of 8 Are you pregnant? date due: Apart from your daily activities do you exercise? 5+ days/week occasionally 3-4 days/week zero 1-2 days/week Do you drink caffeinated beverages? /day Do you smoke? /packs day What is your stress level? low medium high Medication Please list any prescription and/or over the counter medication you are currently taking. (pain pills, injections, skin patches, aspirin, multi vitamins, etc.)
Page 6 of 8 Past Current Medical History Have you ever had/benn diagsed with any of the following conditions? (check all that apply) Heart Problems Chemical dependency HIV High blood pressure Stroke Depression Kidney problems Lung problems/asthma Thyroid incontinence Epilepsy / seizures / dizziness Blood disorder/anemia Diabetes Multiple Sclerosis Arthritis - OA/RA osteopenia/osteoporosis Allergies Head injury Fractures Circular/vascular problems Stomach problems Infections disease (i.e. hepatitis, tuberculosis, etc.) Parkinson s Cancer Spine problems / surgery List any other surgeries other Family History Has anyone in your immediate family ever been diagsed with any of the following? Diabetes High blood pressure Stroke Arthritis OA/RA Heart disease Psychological condition Cancer other
Page 7 of 8 Living Situation live alone live with family members/others/caregiver home / apartment / retirement complex driving other Environment stairs (railing) stairs ( railing) stairs elevator other Previous Functional Level Independent in all activities (work, home, recreation, community) Self Care Independent (bathing, toileting, dressing, etc.) Difficulty performing self care activities Need assistance with self care activities Difficulty performing household chores Social / Recreational / Leisure Limited in What are your goals for therapy?
Page 8 of 8 Work History Occupation full time retired part-time student self unemployed other Physical activities at work sitting phone use heavy equipment operation standing repetitive lifting computer use driving heavy lifting Current working status full duty restricted duty work days missed If t performing your rmal activities at work, do you plan to return to your previous activity level? Are you seeking disability or are you consulting an attorney for this condition? Patient / guardian signature: M.D. follow up date: Reviewed by therapist: Date: Please fill out, print, and bring this form with you to your first appointment. Please arrive to your first appointment 15 minutes early for check in and insurance verification.