Pre-Exam

Pre-Exam

Please answer the items below as accurate as possible in order to have a better understanding of how we can help. Thank you.
Name*

First InitialLast Name
Phone Number*

Area CodePhone Number
E-mail Address*
If this started because of an auto accident or worker's comp case, what date was the accident?
Where does it hurt?*
Where is the pain/problem?
What caused your pain/problem? If answer to the previous question is 'Others', please specify your concern*
If it is a Motor Vehicle Accident, enter date and details of impact.
(Approximately) when did it start?*
If this started because of an auto accident or worker's comp case, what date was the accident?
Are you working now?*
We want to know how much this is affecting your daily function and tasks.
Occupation (If working)
Can you tell us what is the nature of your work? e.g. desk work, repetitive lifting
What is the No. 1 thing you are unable to do that you absolutely want to be able to do again?*
What would you be doing differently or more of, if you did not have this pain?
Check the symptoms that you're currently experiencing:*

PainEasy fatigueTightness and/or weakness in a muscle or jointLoss of balance/DizzinessDifficulty in doing my daily activitiesDifficulty in performing my duties at workUnable to return to fitness activities/sportOther
Check the conditions that apply to you or to any members of your immediate relatives:*

History of Heart Attack/StrokeHistory of Seizure or EpilepsyHistory of CancerPresence of cardiac device implant (pacemaker, defibrillator)Recent weight gainRecent weight lossPain/symptom wakes me up at nightHistory of fall/s with or without injuryNone of the above applies to meOther
Have you ever had the same problem before? *
If YES, you had same problem before, when and please describe.
In your understanding, what do you think will make it better? *
How optimistic are you that you'll get better?*
What are some potential obstacles to you getting better?*
Some examples of challenges: Busy schedule, Transportation to and from clinic, Highly stressful situations at work or at home right now
Over the next 30 days, how many hours per week will you commit to getting better?*
Would you be able to commit time to follow through on your plan of care?
What are you expecting from therapy?
There are no right or wrong answers, we want to have a better understanding of your expectations and what you think works as part of your individualized care.

On the scale, what was your worst pain or symptom level in the past couple days?*

	0	1	2	3	4	5	6	7	8	9	10

0 is Best, 10 is Worst

Are you currently taking any medication?*

YesNo
List any/all medication/s you are taking (for any medical condition).
Do you have any allergies? (Including meds, latex and adhesives like kinesiotape)*

YesNoNot SureOther
If you have allergies, please list them down. *
History of CA?*
Epilepsy?*
Seizure ?*
HIV ?*
Blood Clot?*
Active Infections?*
History of Surgeries?*
Any prior treatment done? *
Tests/Imaging: (e.g. Xray, MRI, CT Scan)*
Any Bowel issues (such as constipation or diarrhea)?*
Any Bladder issues (such as incontinence, frequency or urgency)?*
LIFE STYLE:
Nutrition: Any specific diet?*
Sleep: How many hours on average?*
Hydration: How many glasses of water a day? *
Stress:*

LowMediumHigh
Physical Activity: How often do you exercise and what exercises do you do?*
What is your number one goal for this visit?*
I understand that my candidacy for a rehabilitation program will be dependent upon my ability and willingness to improve. I have answered the questions above honestly and accurately to the best of my ability. The doctor/therapist will determine whether or not I am a viable candidate for a rehabilitation program and that my approval into their program is not guaranteed. Please sign below. *

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Date*

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