PATIENT SELF-ASSESSMENT FORM
This tool has been created to help you determine your current physical state. With its result, you will be provided information on what you need to do - whether you just have to consult a licensed manual physical therapist or you need to receive a treatment. Answer this form truthfully to get a more accurate result.
First Name
*
Last Name
*
Email
*
example@example.com
Mobile Number
*
Please enter a valid phone number.
Format: (0000) 000-0000.
What is your chief concern?
*
Please Select
Head
TMJ
Neck
Shoulder
Elbow
Wrist and hand
Upper Back and Cervical Spine
Mid Back and Thoracic Spine
Lower Back and Lumbar Spine
Hip
Lower Leg
Ankle and Foot
Description of your chief concern.
*
Back
Next
Your Assessment
In a scale of 0 - 10, 0 means no pain and 10 means most painful, how would you rate your level of pain?
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0
1
2
3
4
5
6
7
8
9
10
Raw Score 1
How long have you been experiencing your concern?
*
1 month
2 - 4 months
5 - 11 months
1 year and more
Raw Score 2
How would you describe the level of discomfort you have with your concern?
*
No feeling of numbness due to fatigue
Intermittent feeling of numbness due to fatigue
Longer hours of feeling of numbness due to fatigue
All day feeling of numbness due to fatigue
Raw Score 3
With this concern, how much daily activities can you still perform?
*
100% completion
76% - 90% completion
61% - 75% completion
60% and below completion
Raw Score 4
How many areas do you feel you have concerns with?
*
1 area
2 areas
3 areas
4 areas and more
Raw Score 5
Your Score
Submit
Should be Empty: