Get Physical New Patient / Client Questionnaire

NEW PATIENT/CLIENT QUESTIONNAIRE
Date

MonthDayYear
Date
Last name
First
Middle Initial
Age
Date of Birth

MonthDayYear
Date
Current Height
Current Weight
Nickname
Gender
Pronoun Preferred
Address
Cell Phone
Home Phone
Occupation
How did you learn about GET PHYSICAL LLC?
Do you give me permission to share findings and converse with your primary doctor?
Primary Care Physician
Phone
Name of spouse, partner, parent, relative, or friend
Phone
When was the last time you experienced optimal health?
How would you describe your current overall health condition?
How motivated are you to make changes to your health?
What health concern would you like to discuss in your initial visit?
Do you have other health concerns you would like to address at subsequent visits? List in order of importance!
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What are your thoughts on these concerns? Do you have any ideas as to what might be the underlying cause of your symptoms? Please indicate for each concern.
Have you received therapy for this condition? If yes, what kind and when?
Has your condition been getting:
Are your symptoms:
What makes your condition better? (please check all that apply)

BendingRisingBetter in a.m.MovementWalkingBetter as day progressesRestStairsHeatLyingBetter in p.m.IceSittingMedicationStandingChanging Position
What makes your condition worse? (please check all that apply)

BendingRisingWorse in a.m.MovementWalkingWorse as day progressesRestStairsHeatLyingWorse in p.m.IceMedicationSittingStandingChanging position
Medical/Surgical History (Please check any conditions you have or have ever had)

ArthritisMuscular DystrophySeizures/EpilepsyKidney problemsHeart ProblemsDepressionCancerBroken BonesMultiple SclerosisOsteoporosisBlood DisordersInfectious DiseasePacemakerSkin DiseasesHead InjuryParkinson’s DiseaseThyroid ProblemsRepeated InfectionsStrokeCirculation/vascular problemsSpinal Cord InjuryDiabetesUlcers/Stomach ProblemsLung ProblemsAny Metal Implants
Within the past year, have you had any of the following symptoms?

Chest PainHeadachesJoin pain or swellingHearing ProblemsPain at nightDifficulty sleepingCoughVision ProblemsFever/chills/sweatsDifficulty walkingNausea/vomitingShortness of breathDizziness or blackoutsLoss of balanceHeart PalpitationsUrinary problemsDifficulty SwallowingCoordinating problemsFallsLoss of appetiteBowel ProblemsWeight Loss/GainWeakness
Current Medications
Do you participate in any sports, exercise programs, or activities on a regular basis?
If YES, you participate in
Because of your concerns or issues, what specific activities are you have difficulty with?
Do you consume caffeine?
If YES, how much per day?
Do you smoke or have a history of smoking?
If YES, how many packs per day or date you became a non smoker

MonthDayYear
Date
How many ounces of water do you consume per day?
Do you have house pets? [Note: House pets can pose significant fall risks.]
If YES, what type of pet?
If pet is a dog, who is primary dog walker?
What are your goals/outcomes you hope to achieve by working with me?
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Name
Signature

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Date

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Date
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NEW PATIENT/CLIENT QUESTIONNAIRE