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patient information Last Name: First Name: MI: Date of Birth: / / (MM / DD / YYYY) Marital Status: single married other Sex: male female Home Address: City: State: Zip Code: Mailing Address (if different from Home Address) : City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Email Address: Desired primary form of contact: email home # cell # work # Emergency Contact/Legal Guardian: Relationship to Patient: Contact Phone Number: Who referred you to IPA Physio: Name of Primary Care or Referring Physician: Contact information for Primary Care or Referring Physician: insurance information Insurance Company: Group Number: Policy/ID: Planholders Name (If not Patient): Planholders DOB: / / (MM / DD / YYYY) Relationship to Patient: Planholders Home Address: Planholders City: State: Zip: **It is the patient s or guardian s responsibility to inform IPA Physio of any changes to your insurance coverage or carrier** advanced physical therapy page 1

Reason for visit: injury accident surgery Describe your current injury(ies): When did your pain start? What do you think caused your pain? Why? Since its initiation, have your symptoms: become worse become better remained the same What increases your pain? What eases your symptoms? Describe any relevant previous injuries: List any other relevant medical history (i.e. conditions or surgeries) that your therapist should be aware of (please also fill out next page): Have you undergone any diagnostic testing (i.e. MRI, X-Ray, Nerve Conduction, etc)? Are You Taking Any Medications? Yes No If yes, please list medications and dosage: What are YOUR goals for treatment?: advanced physical therapy page 2

past medical history Please answer the questions below to the best of your ability prior to having your initial visit with your physical therapist. REVIEW OF SYSTEMS Please mark the appropriate yes or no box (Describe any Yes answer on the following page): yes: no: General (e.g. fever or chills, poor general health, unexplained weight loss, fatigue) Skin Eyes Ears Nose (e.g. rashes, new skin lesions, or a change in moles) (e.g. blurred vision, or change in visual acuity) (e.g. ear pain or difficulty hearing) (e.g. nasal congestion, discharge, or bleeding) Mouth/throat Respiratory (e.g. sore throat, or difficulty swallowing) (e.g. shortness of breath, cough, wheezing) Cardiovascular Gastrointestinal (e.g. nausea, high/low blood pressure, palpitations) (e.g. vomiting, diarrhea, constipation, abdominal pain, discolored stools) Irregular Bowel Movements (e.g. less than one per day) Genitourinary (e.g. problems initiating/controlling my bladder or urinary infrequency) Women s Health (e.g. pain with intercourse, painful menstrual cycle, etc.) Endocrine (e.g. heat or cold intolerance, weight loss or gain, increasing thirst) Hemato-immunologic (e.g. bruise easily, bleeding) Bone Health Psychiatric (e.g. osteoporosis, osteopenia, etc.) (e.g. depression, anxiety, suicidal thoughts or attempts) Smoking (e.g. occasional, daily, etc.) advanced physical therapy page 3

Please detail any YES answers from the previous page: If your symptoms fit one of these two categories, please select the appropriate responses. Select the number that describes your symptoms TODAY: (0 = No pain or Never there, 10 = Worst possible or Always there) NECK / ARM 1. How bad is your neck/upper back pain? 2. How frequent is your neck/upper back pain? 3. How bad is your arm pain? 4. How frequent is your arm pain? 5. How bad is your numbness/tingling? 6. How frequent is your numbness/tingling? LOWER BACK / LEG 1. How bad is your back pain? 2. How frequent is your back pain? 3. How bad is your leg pain? 4. How frequent is your leg pain? 5. How bad is your numbness/tingling? 6. How frequent is your numbness/tingling? 1989 The Institute of Physical Art FMUQ; Version 9.0; Revised 3/2015 Adapted by Dean Hazama, PT, CFMT advanced physical therapy page 4

Draw on the figure below where you feel or have felt related pain and/or symptoms. SYMPTOMS YOU FEEL TODAY: Use X marks SYMPTOMS PRIOR TO TODAY: Use O marks Please indicate the intensity of current, best, and worst pain levels over the past 24 hours on a scale of 0 (no pain) to 10 (worst pain imaginable) 0 1 2 3 4 5 6 7 8 9 10 none mild moderate severe Current / 10 Best in past 24 hours / 10 Worst in past 24 hours / 10 advanced physical therapy page 5

advanced physical therapy services IPA Physio is made up of a group of dedicated and compassionate manual physical therapists whose goal is to improve the lives of our patients using thorough evaluation and treatment techniques. The emphasis of care is Functional Manual Therapy, which includes Functional Mobilization, soft tissue and joint mobilization, posture and movement training, and individualized exercise programs. what to expect on first visit Your initial evaluation will be completed in 1 hour and treatment may begin on the first visit if time permits. You should wear comfortable clothing that can easily expose the injured joint or body part. Our therapists can perform the physical therapy evaluation and treatment without a doctor s prescription. If you have any X-rays, MRIs, or other medical documentation related to your injury, please bring these to the first appointment. mission statement To create a movement culture that facilitates thriving, challenges the norms, and optimizes the human experience by providing the highest quality methodical physical therapy. IPA Physio s goal is to assist patients in their recovery from injury so they can return to a lifestyle that they can enjoy. We believe strongly in promoting overall wellness and injury prevention. We design customized treatment programs to meet each patient s specific needs, utilizing a Functional Manual Therapy Approach. Our Physical Therapists are committed to ongoing continuing education to ensure professional growth. All of our Therapists have obtained additional Functional Manual Therapy certifications and advanced professional training that require years of consistent dedication to obtain. We believe in ongoing mentorship and continued clinical research as a means to continuously improve our patient outcomes. It is this combination of clinical expertise, genuine caring, and a strong community reputation that sets IPA Physio apart. Our therapists comply with privacy regulations set forth by HIPAA and will protect each patient s privacy without compromise. IPA PHYSIO is an out of network provider of physical therapy. As a courtesy, we will submit claims to your insurance company to assist with reimbursement of out of network benefits. IPA PHYSIO cannot guarantee reimbursement. IPA PHYSIO is not a Medicare provider. We cannot submit to Medicare for our patients. By signing below, I certify all information on this form is true and correct to the best of my knowledge. Signature: Date: advanced physical therapy page 6

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