Name: Date of Birth: Primary Care Physician: Referring Physician: Have you had physical therapy during this calendar year? Yes No Have you had occupational therapy during this calendar year? Yes No If Yes, where? Current work status: Full-Time Part-Time Self-Employed Unemployed Disability Retired Other Are you pregnant or is there a possibility that you could be pregnant? Yes No What issues are seeking help for from physical therapy/occupational therapy? Who else have you seen for this issue (check all that apply)? No one Medical Doctor Chiropractor Physical Therapist Occupational Therapist Massage Therapist Physiatrist Athletic Trainer Speech Therapist Nutritionist Other: What tests have you had? X-Ray CT Scan MRI EMG PET Scan Ultrasound Venous Doppler Angiogram Biopsy Mammogram Other How would you rate your overall health? Excellent Very Good Good Fair Poor Do you use tobacco? Yes No If Yes, how much? What surgeries have you had (Check all that apply)? Check if you ve attached a separate sheet Cataract Gallbladder Prostate Carpal Tunnel Tonsillectomy Hernia Joint Heart Bypass Open Heart Skin Graft Back Neck Bladder D & C Splenectomy Appendectomy Hysterectomy Breast Surgery Tubal Ligation C-Section Colon/Bowel/Intestine Kidney Thyroidectomy Fracture Repair and Location(s) Other:
Past Medical History (Check all that apply): Check if you ve attached a separate sheet MRSA Diabetes Hypertension Mitral Valve Prolapse Heart Attack Congestive Heart Failure DVT/Clots Irregular Heartbeat Pacemaker Internal Defibrillator Asthma COPD Emphysema Chronic Bronchitis Tuberculosis Frequent Heartburn Gastric Reflux Hiatal Hernia Cirrhosis Hepatitis Gallbladder Disease Stomach Ulcer Thyroid Disease Kidney Stone(s) Kidney Infection Kidney Dialysis Anemia Bruising HIV/AIDS Stroke/TIA Epilepsy/Seizures Alzheimer s Parkinson s Disease Headaches Restless Leg Syndrome Fibromyalgia Spinal Cord Injury Artificial Joint Arthritis Depression Anxiety Mental Illness Metal Implants Osteoporosis Osteopenia Vitamin Deficiency Other Allergies (list all): Current Medications: Check if you ve attached a separate sheet
Cancer Specific Questions: Do you currently have or have you had cancer? Yes No What type of cancer? List surgeries related to treatment of cancer, including the number of lymph nodes removed (if applicable): Check if you ve attached a separate sheet 1) Date 2) Date 3) Date 4) Date 5) Date List any complications from your surgery/surgeries (infections, increased time of the drains, wounds, etc.): List previous treatments or current treatments below: Check if you ve attached a separate sheet Radiation (Please include the start date of treatment, when treatment was completed, and any complications that may have occurred): Chemotherapy (Please include start date of treatment, when treatment was completed, and any complications that may have occurred. If treatment was unable to be completed, please note that as well.):
Lymphedema Specific Questions: Have you been formally diagnosed with lymphedema? Yes No Are you currently experiencing any swelling? Yes No If yes, what body parts have been affected? Mark the locations on the picture below with *** to indicate your areas of swelling When did the swelling start/how long has it been going on? What, if anything, have you done to treat the swelling? Have you used compression bandages/wraps or used a compression pump in the past? Yes No Do you currently have compression garments? Yes No If yes, list what garments you currently have: How old are your garments/compression bandages? Where did you get them? Do they fit? Yes No Did they professionally fit you at the time you purchased the garments? Yes No Are you interested in being fit for a compression garment today? Yes No Would you like to order more garments today? Yes No
Please rate your pain today (if applicable): 0 1 2 3 4 5 6 7 8 9 10 (No Pain) (Annoying) (Uncomfortable) (Agonizing) (Horrible) (Unbearable) Please rate your pain at its best (lowest) and at its worst (highest) (if applicable): 0 1 2 3 4 5 6 7 8 9 10 (No Pain) (Annoying) (Uncomfortable) (Agonizing) (Horrible) (Unbearable) Please indicate the location of your symptoms on the diagram. Use the key below to indicate the kind of symptoms you are having. Sharp: Shooting: Dull Ache: OOOO Burning: XXXX Numbness/Tingling: //// Other: ++++ Please tell us what things you would like to return to doing that you are having difficulty doing now.
Name: First Nickname: Last Male/ Female Married/Single/Other Date of Birth: SS # Home Address: City: State: Zip: Email: Home Phone: ( ) Cell Phone: ( ) Employer: Work Phone: ( ) Employer Address: City: State: Zip: How would you like to be reminded about your appointments? E-Mail Text Message If text message please list your cell phone provider: AT&T US Cellular T-Mobile Verizon Sprint Other Who can we thank for referring you to the clinic? Emergency Contact: Relationship to Patient: Phone number: ( ) Responsible Party/Insured Spouse or Parent (If different from above) Name: Relationship to Patient: Phone number: ( ) Insured Date of Birth: Insured SS#: Address: City: State: Zip:
What prompted your visit? Referring Physician: Other accident Is this: Work related Vehicle accident Date of Injury and/or surgery: Type of injury/surgery: Are there any other insurances involved in your injury/surgery (auto, home, etc)? Yes No If yes, please list: Are you receiving or have you received home health, chiropractic care, or other physical therapy this year? Yes No I certify that all of the information provided here is true and correct. Patient/Guardian Signature Witness Signature Date