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?
*
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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?
*
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Yes
No
Have you smoked in the past?
*
-
Yes
No
Do you exercise?
*
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Yes
No
If yes, describe the exercise (what type, how often)
*
Have any family members (parents, siblings, aunts, uncles, grandparents) had any of the following conditions? (Check all that apply)
Other Family History Condition(s)
Select any and all of the conditions below that you have ever personally had?
Select any of the following that you have had WITHIN the past year
Other Personal History Condition(s)
Have you had surgery?
*
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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?
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Yes
No
Women Only: Are you pregnant?
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Yes
No
Women Only: Have you given birth in the past 5 years?
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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?
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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?
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Yes
No
What are your goals in attending Physical Therapy?
*
