Were you referred by a physician?
name of physician
What are we seeing you for?
for example, R knee pain
Date of onset (estimate if unknown)
Are you currently taking any medication?
Please list all medications and dose
Do you currently have or have you had any of the following:
Respiratory Problems other than asthma (ie COPD)
Neurological Problems (ie stroke/TIA, Parkinson's, MS, TBI)
Gastrointestinal Problems (ie IBS)
Infectious Disease (ie Hep C, HIV, MRSA)
Asthma (exercised induced or other)
Cardiac Conditions (ie heart attack, heart failure, angina/chest pain)
High Blood Pressure
Headache or Migraine
Low Blood Pressure
Pain with cough/sneeze
Numbness in the arms or legs
Gait abnormalities (ie ataxia, etc)
History of falls
No known medical conditions
Please describe in detail any of the above problems:
for example, breast cancer 2010, fell 2 times this year
Do you have any allergies?
for example, latex, seasonal, etc.
Please list any other medical issues or past surgeries you would like us to know:
Are you pregnant?
Since the onset of your primary complaint:
Dizziness or changes in gait?
Have you lost or gained weight without trying?
Difficulty or change in bowel or bladder function?
Malaise (overall "sick" feeling)?
Do you use or do you have history of using tobacco?
Do you use or do you have history of using illegal drugs?
How often do you consume alcohol?
Questions pertaining to mental health:
Are you being treated for depression?
If yes, explain:
for example, seeing a therapist
During the past month, have you been bothered by feeling down, depressed or hopeless?
During the last month have you often been bothered by little interest or pleasure in doing things?
Have you had any thoughts of suicide or harming self?
Describe your sleep patterns:
sleeping as usual
sleep reduced by at least 2 hours
getting less than 3 hours sleep a night
Describe your stress level:
What are your goals for physical therapy?
for example, run without pain
(OPTIONAL) What song pumps you up?
Patient/Parent/Guardian Signature (use finger or mouse)
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