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Name:

Gender: Male Female Would Rather Not Disclose

Age:

Smoker: Yes No

(If yes, how many packs per day?)

Pregnant: Yes No

(Due Date)

Occupation:

What do you do to stay active during the week? How often?

Are you currently taking any medications/supplements? Yes No

If yes, please list:

Have you had an x-ray, MRI, or other imaging study related to your current symptoms? Yes No

If yes, please list test and date.

Past Medical History: Please check each condition that you have been told you have (or had).

Cancer Diabetes Kidney Disease Liver Disease

Bone Fractures Osteoporosis Osteoarthritis Rheumatoid Arthritis

Fibromyalgia Muscle Disease History of Falls

Ulcers Allergies Asthma Lung Disease

Neuropathy Thyroid Dysfunction Stroke Angina/Chest Pain

Pacemaker/Cardiac Device Heart Disease Daily Alcohol (3 or more glasses)

Hypertension (High Blood Pressure) Hypotension (Low Blood Pressure)

Any other? (If yes, please explain.) Yes No

Please list any previous surgeries, medical procedures, and/or hospitalizations with dates:

Do you take blood thinners? Yes No

Are you allergic to latex? Yes No

Other Allergies:

Currently I am experiencing: (check all that apply to your current symptoms)

Fever/Chills/Sweat Changes in Appetite Difficulty Swallowing

Shortness of Breath Unexplained Weight Loss Headaches or Migraines

Hearing Problems Blurred Vision Dizziness or Vertigo

Sudden Fainting Spells Weakness in Legs Unsteady Gait/Walking

Recent Increase in Stress or Anxiety Bladder/Bowel Changes

Numbness/Tingling/Burning Sensation in Arms or Hands

Numbness/Tingling/Burning Sensation in Legs or Feet Other

In the past month, have you often been bothered by feeling down, depressed, or hopeless? Yes No

In the past month, have you often been bothered by little interest or pleasure in doing things? Yes No

Current Symptoms:

Where are you currently having symptoms? What brought you in to Physical Therapy?

What date (approximately) did your present symptoms start?

How did it start? (gradually, suddenly, injury)

My symptoms are currently: Getting Better About the Same Getting Worse

Have you ever had this problem before? Yes No

Have you already received treatment for this problem? Yes No

If so, how was this problem treated and was it successful?

Does your problem prevent you from getting a full night's sleep? Yes No

Please answer the questions below based on the complaints for which you are primarily seeking treatment.

Do you have increased pain with activity? Yes No

Identify up to 3 different important activities that you are unable to do, having difficulty with, or that increases your symptoms.

1.
2.
3.

What makes your symptoms better?

Using the scale above, which number represents your current level of pain?
0 1 2 3 4 5 6 7 8 9 10

Using the scale above, which number represents your current level of activity?
0 1 2 3 4 5 6 7 8 9 10

What is your personal goal for therapy?

How did you hear about us?
Doctor Referral Friend Facebook Instagram Google

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Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

May 14, 2021 11:22 am AKST

MHQ Doc Edits Uploaded by Optimum Health and Wellness - info@bolddesign.group IP 206.223.197.206

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