Name
Date of Birth
/
Month
/
Day
Year
Date
Family Physician/Internist
Neurologist
Special Learning Needs (such as ADHD, learning disability, dyslexia, etc.)
Date of Injury
/
Month
/
Day
Year
Date
Rows
Any History of...
High Cholesterol
Yes
No
Hypertension (high blood pressure)
Yes
No
Hypotension (low blood pressure)
Yes
No
Heart Disease
Yes
No
Smoking
Yes
No
Stroke
Yes
No
Brain Injury
Yes
No
Multiple Sclerosis
Yes
No
Seizure Disorder
Yes
No
Dementia Alzheimer's
Yes
No
Are you in pain?
Please Select
Yes
No
Location and rate pain on scale (1 10)
If answered yes to any of the above questions, are you under the care of MD for these conditions?
Please Select
Yes
No
In the past month, have you frequently been bothered by feeling down, depressed or hopeless?
Please Select
Yes
No
In the past month, have you frequently been bothered by having little interest in things or have you lost pleasure in doing?
Please Select
Yes
No
Surgery within the past three months?
Please Select
Yes
No
Have you fallen within the past year (if so how many times)?
Do you feel unsteady?
Please Select
Yes
No
Do you experience dizziness or vertigo?
Please Select
Yes
No
Do you have vision problems not corrected by glasses?
Please Select
Yes
No
Do you have memory and/or cognitive difficulties?
Please Select
Yes
No
Do you have difficulty speaking and/or communicating?
Please Select
Yes
No
Do you have difficulty swallowing?
Please Select
Yes
No
Do you experience fatigue/tiredness?
Please Select
Yes
No
What are your rehabilitation goals?
What is your job/profession?
Are you currently working?
Please Select
Yes
No
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