Patients Full Name (First, Middle, Last) *
Age *
Primary Phone *
Email Address *
Employer
Occupation
Social and Vocational Services are available to you at no charge. Do you wish to access these services? *
-
Yes
No
Rate your pain (0 is no pain; 10 is worst pain) *
-
1
2
3
4
5
6
7
8
9
10
Have you ever had physical or aquatic therapy before? *
-
Yes
No
Do you currently smoke tobacco? *
-
Yes
No
Have you smoked in the past? *
-
Yes
No
Do you exercise? *
-
Yes
No
If yes, describe the exercise (what type, how often) *
Other Family History Condition(s)
Other Personal History Condition(s)
Have you had surgery? *
-
Yes
No
If yes, please describe & give dates (specify right or left)
List medications by name you are presently taking
List any allergies including Drug and Medication Allergies
Men Only: Have you had prostate disease?
-
Yes
No
Women Only: Are you pregnant?
-
Yes
No
Women Only: Have you given birth in the past 5 years?
-
Yes
No
Women Only: If yes, did you have any complications with pregnancy/delivery?
Women Only: Have you had gynecological difficulties or trouble with your period?
-
Yes
No
Describe the problem for which you seek physical therapy: *
When did the problem begin? *
How did it begin? *
What if anything causes your pain to worsen? *
What if anything causes your pain to improve? *
Have you ever had the problem before?
-
Yes
No
What are your goals in attending Physical Therapy? *
