Physical Therapy Intake

EMPOWERED PHYSICAL THERAPY

Kara McKeown, PT, MSPT
New Patient Questionnaire
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Age
Height
Weight
Date of Birth

MonthDayYear
Date
Occupation
Phone Number

Area CodePhone Number
Emergency contact:

First NameLast Name
Emergency contact Phone Number

Area CodePhone Number
Primary care Physician

First NameLast Name
Specialist Physician

First NameLast Name
Medical History & Goals

Please help me to better serve you by taking a few minutes to provide this information
What are your goals for our time working together?
Briefly describe your current health and lifestyle.
Where do you want to be physically?
Chief complaint/ailment/injury
Briefly Describe the onset of how pain/symptoms began, or how injury occurred
Have you received therapy for this condition?

YesNo
When?
How Many Visits?
Has your condition been getting:

WORSESAMEBETTER
Are your symptoms:

CONSTANTINTERMITTENT
At Best Which Number Corresponds With Your Pain

12345678910
At Worse Which Number Corresponds With Your Pain

12345678910
What decrease/makes your condition better?

BendingSittingRisingChanging PositionsLyingWalkingStandingMovementRestHeatIceMedicationBetter In AMBetter In PMBetter as Day ProgressesN/A Cast Just Removed
What increases/makes your condition worse?

BendingSittingRisingprolonged PositioningWorse as Day ProgressesMovementStandingWalkingLyingN/A Cast Just RemovedRestStairsCoughWorse in AMSneezeDeep BreathMedicationWorse in PM
Previous Medical Interventions

X RAYMRIInjectionsCatscanOther
Please check the box if you have had any of the following medical conditions

Difficulty SwallowingArthritisHigh Blood PressureHeart TroublePacemakerEpilepsy / SeizureHistory of Drug AbuseMyofascial PainCancerMotion SicknessFever / Chills / SweatsUnexplained Weight LossBlood ClotsShortness of BreathHistory of SmokingDiabetesFibromyalgiaStrokeOsteoporosisAnemiaBleeding ProblemsHIV / HepatitisHistory of Alcohol AbuseDepression / AnxietyPregnancy
List past medical History and dates of occurrence. Include surgeries, accidents and other traumas.
Please list any Medications or supplements you are taking. The condition for which you are using them for and their effectiveness.
Please list any allergies
Please list the activities that you would like to be able to do as a result of therapy. Task/Activity duration/How often/by when? I would like for you to take some time on this section and come up with the goals that really mean something to you.
On a scale from 1-10 rate your feeling on each subject, with 1 being the lease and 10 being the most.

How do you feel in regards to your health and fitness?

	1	2	3	4	5	6	7	8	9	10

1 is Worst, 10 is Best

Are you ready to make a change to your health?

	1	2	3	4	5	6	7	8	9	10

1 is Worst, 10 is Best

How ready are you to dedicate yourself to a new plan?

	1	2	3	4	5	6	7	8	9	10

1 is Worst, 10 is Best

How excited are you to make this change in your life?

	1	2	3	4	5	6	7	8	9	10

1 is Worst, 10 is Best

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EMPOWERED PHYSICAL THERAPY

New Patient Questionnaire

Medical History & Goals