"Medical Intake Form - Walker Physical Therapy&sports Injury Center"

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MEDICAL INTAKE FORM
Thank you for choosing Walker Physical Therapy and Sport Injury Center.
Please take your time while answering the following questions as it will help us give you the best care possible.
PATIENT HISTORY
Patient Name: _______________________________________
Age:______________
Diagnosis:____________________________
Referring Physician:_______________________________ Recent Surgery and Dates:____________________________________________
Medications:
1. ____________________________________ Dosage: ________________________ Frequency: ____________________
2. ____________________________________ Dosage: ________________________ Frequency: ____________________
3. ____________________________________ Dosage: ________________________ Frequency: ____________________
4. ____________________________________ Dosage: ________________________ Frequency: ____________________
Other Medications/Vitamins: ___________________________________________________________________________________________
CURRENT CONDITION
Date of injury:
Mechanism of injury:
Describe your chief complaint / concern:
Identify any position / activity that eases your symptoms:
Identify any position / activity that aggravates your symptoms:
What is your goal with physical therapy:
BODY CHART / PAIN LEVEL
Mark areas where you feel symptoms. Use the symbols to describe
your symptoms and rate the pain 0-10 with 0 as no pain and 10
as so intense you would need to go to the emergency room.
T = Tingling
N = Numbness
P = Pain
S = Shooting / Sharp pain
Do your symptoms (check one:)
o Come and go
o Constant
o Change with activity
Does your pain / symptoms subside while resting at night? o Yes
o No
MEDICAL INTAKE FORM
Thank you for choosing Walker Physical Therapy and Sport Injury Center.
Please take your time while answering the following questions as it will help us give you the best care possible.
PATIENT HISTORY
Patient Name: _______________________________________
Age:______________
Diagnosis:____________________________
Referring Physician:_______________________________ Recent Surgery and Dates:____________________________________________
Medications:
1. ____________________________________ Dosage: ________________________ Frequency: ____________________
2. ____________________________________ Dosage: ________________________ Frequency: ____________________
3. ____________________________________ Dosage: ________________________ Frequency: ____________________
4. ____________________________________ Dosage: ________________________ Frequency: ____________________
Other Medications/Vitamins: ___________________________________________________________________________________________
CURRENT CONDITION
Date of injury:
Mechanism of injury:
Describe your chief complaint / concern:
Identify any position / activity that eases your symptoms:
Identify any position / activity that aggravates your symptoms:
What is your goal with physical therapy:
BODY CHART / PAIN LEVEL
Mark areas where you feel symptoms. Use the symbols to describe
your symptoms and rate the pain 0-10 with 0 as no pain and 10
as so intense you would need to go to the emergency room.
T = Tingling
N = Numbness
P = Pain
S = Shooting / Sharp pain
Do your symptoms (check one:)
o Come and go
o Constant
o Change with activity
Does your pain / symptoms subside while resting at night? o Yes
o No
CURRENT SYMPTOMS / CONDITION
(check all that apply)
o Cancer / infection
o Recent falls
o Abdominal pain / pulsating
o Fever, chills, night sweats
o Balance / dizziness
o Blood in urine
o Nausea / vomiting
o Weakness / joint pain
o Changes in bowel / bladder
o Unexplained weakness / pain
o Numbness / tingling
o Difficulty swallowing
o Pregnancy
o Shortness of breath
o Diabetes
o Smoker
o Excessive cough
o Excessive thirst
o Confusion / memory loss
o Severe pain in calf
o Insulin dependent
o Pacemaker
o High blood pressure
Injection time
During the past month, have you been feeling down, depressed, or hopeless?
o Yes
o No
During the past month, have you been bothered by having little interest or pleasure in doing things?
o Yes
o No
If yes to either question above, is this something you would like help with?
o Yes
o No
PAST MEDICAL HISTORY
List any medical condition you have been diagnosed with or hospitalized for:
Patient / guardian signature:
Date:
Physical Therapist Use Only
(notes for follow-up questions)
BP
Falls efficacy scale
Tug
SLS (R)
(L)
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