Physical Therapy History Intake Form

Referring MD:   ________________________________           Family MD: _______________________________ Today’s Date: _________________________________                                            

HISTORY:

1.        What is your reason for coming to therapy today?                                                        _____________________________________________________________________________________________________________________________________________________________________________________________________________________                                                                                                   

2.        When did your problem begin?                                                                             __________________________________________________________________________________________________________________________________________________________________________________________                                                                                                                     

3.        How did your problem start?                                                                                     __________________________________________________________________________________________________________________________________________________________________________________________

                                                                                                             

4.        Please circle the appropriate answer:

         MRI                  X-Ray                  CT Scan          

a)        Do you have high blood pressure?         Yes         No

b)        Do you currently have an infection?         Yes         No

c)        Do you have diabetes?         Yes         No

d)        Do you currently have heart trouble?         Yes         No

e)        Do you have asthma?         Yes         No

f)        Do you currently have osteoporosis?         Yes         No

Patient Intake Form (continued)

g)        Do you currently have active cancer?         Yes         No

h)        Are you pregnant?         Yes         No         NA

i)        Do you have other health problems?           Yes         No

     If yes, please list: ____________________________________________      

j)        Is there anything that your doctor told you not to do?         Yes         No

     If yes, please list: ____________________________________________

      __________________________________________________________

k)        Are you currently taking any prescription or over-the-counter drugs?         Yes         No

     If yes, please list: ____________________________________________                         __________________________________________________________                  

l)        Are you currently taking any herbal preparations / vitamins?         Yes         No

     If yes, please list: ____________________________________________                         __________________________________________________________                  

m)        Are you allergic to adhesives/tape, latex, or bee stings?         Yes         No

             If yes, please list: ____________________________________________                  

n)        Have you had any surgeries?         Yes         No

      If yes, please list: ___________________________________________                         __________________________________________________________                  

o)        Have you had physical therapy previously for the same problem?         Yes         No

p)        Are you receiving other treatments for this problem at this time?              Yes         No

              If yes, please list: ___________________________________________                  

              __________________________________________________________                  

q)        What other kind of tests have been done for your current problem?                  

 List: ______________________________________________________

        Results: ____________________________________________________                  

Patient Intake Form (continued)

r)        Have you been hospitalized in the past year for this condition?         Yes         No    

If yes, when and for how long?: _________________________________          

s)  Does anyone come to your home to provide health care needs (nursing, social work, physical/occupational/respiratory needs)?         Yes         No

t)  Do you have any metallic implants (i.e. pacemaker)?         Yes         No                           

If yes, please list?: ____________________________________________

                     

5.        When is your next appointment with the doctor who sent you to us?   __________________________                                                      

6. PAIN: 

 

1. Do you have pain now?            No                   Yes, Location/Type:   _         _         _         _         _         _         

 

What makes it better?   _         _         _         _         _         _         _         _         _         _         _         _         

 

What makes it worse?   _         _         _         _         _         _         _         _         _         _         _         _         

 

Does the pain interfere with your daily life?      No          Yes, Describe:                                                

 

RATE YOUR PAIN ON A SCALE OF 0-10  ( 0 = NO PAIN AND 10 = THE WORST PAIN YOU’VE EVER EXPERIENCED )

________/10  Today

NONE           MILD         MODERATE         SEVERE

Patient Intake Form (continued)

7. BALANCE:

1.        Have you fallen in the last 6 months?    Yes   No     If yes, how many times? _____________

 

2.        Have you had a decrease in your activity level because of a fear of falling?   Yes   No      

 

3.        Are you reluctant to leave your home because of a fear of falling?     Yes   No      

 

What are your goals as a result of attending physical therapy?  

Please check appropriate box.  

◻  Decrease pain

◻  Improve strength

◻ Improve flexibility

◻ Less difficulty with work activities  

◻ Stand longer ___ minutes / hours.

◻ Sleep longer _______ hours  

◻ Sit longer ___ minutes / hours.          

◻ Improve movement  

◻ Less difficulty with home activities

◻ Return to recreational activities / sports activities          

Additional information you’d like to share: ____________________________________________________________________________________________________________________________