"Patient Intake Form - Great Basin Physical Therapy and Performance Center"

ADVERTISEMENT
ADVERTISEMENT

Download "Patient Intake Form - Great Basin Physical Therapy and Performance Center"

536 times
Rate (4.5 / 5) 30 votes
Great   B asin   P hysical   T herapy   a nd   P erformance   C enter
Pa#ent   I ntake   F orm
Patient
Last Name:
_____________________________________________
First Name:
________________________________
DOB:
___________ ____________ ____________
/
/
Age:
_______
DATE:
____________________________________
Occupation:
_______________________________________________________________________________________
Date of Injury:
_____________________________________
Date of Surgery:
__________________________________
Yes
No Are you currently pregnant?
Yes
No
Are you receiving Home Health Care?
What caused your current problem?
______________________________________________________________
_________________________________________________________________________________________________
Have had this problem before?
Yes
No
If Yes when and where?
_____________________________
_________________________________________________________________________________________________
Have your symptoms gotten worse?
Yes
No
What makes your symptoms better?
______________________________________________________________
What makes your symptoms worse?
______________________________________________________________
Are you able to sleep with this problem?
Yes
No
Sometimes
Is your pain worse in the:
Morning
Midday
Evening
All day
List all medications you are currently taking:
_______________________________________________________
_________________________________________________________________________________________________
Your pain: Draw the areas of pain ( / / / / ) ; tingling (XXXX) ; numbness ( > > > > )
Page 1 of 2
REV. 082914
Great   B asin   P hysical   T herapy   a nd   P erformance   C enter
Pa#ent   I ntake   F orm
Patient
Last Name:
_____________________________________________
First Name:
________________________________
DOB:
___________ ____________ ____________
/
/
Age:
_______
DATE:
____________________________________
Occupation:
_______________________________________________________________________________________
Date of Injury:
_____________________________________
Date of Surgery:
__________________________________
Yes
No Are you currently pregnant?
Yes
No
Are you receiving Home Health Care?
What caused your current problem?
______________________________________________________________
_________________________________________________________________________________________________
Have had this problem before?
Yes
No
If Yes when and where?
_____________________________
_________________________________________________________________________________________________
Have your symptoms gotten worse?
Yes
No
What makes your symptoms better?
______________________________________________________________
What makes your symptoms worse?
______________________________________________________________
Are you able to sleep with this problem?
Yes
No
Sometimes
Is your pain worse in the:
Morning
Midday
Evening
All day
List all medications you are currently taking:
_______________________________________________________
_________________________________________________________________________________________________
Your pain: Draw the areas of pain ( / / / / ) ; tingling (XXXX) ; numbness ( > > > > )
Page 1 of 2
REV. 082914
Great   B asin   P hysical   T herapy   a nd   P erformance   C enter
Pa#ent   I ntake   F orm
Tests Performed (check all that apply)
X-Ray
MRI
Epidural
Cortisone
Other:
__________________________________________________________________________________
Past Medical History (Major illness and surgeries):
_________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Do you now or in the past have you had problems with (check all that apply):
Allergies
Osteoarthritis
Rheumatoid Arthritis
Cancer:
Joint pain
Diabetes
Head Injury
Heart problems
Stroke
Heart Attack
Seizures
Blood Pressure
Head Aches
Thyroid
MS
Asthma
Osteoporosis
Balance Issues
Pacemaker
Parkinson’s
Defibrillator
Other:
_____________________________________________________________
What are your Physical Therapy Goals?
Decrease pain
Increase strength
Increase endurance
Increase range of motion
Return to work
Return to prior level of function
Return to sport activities:
________________________________________________________________
Other Pertinent Information:
_____________________________________________________________
____________________________________________________________________________________________
Patients Initials:
Therapist Initials:
_______________
_______________
Page 2 of 2
REV. 082914
Page of 2