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Rise Physical Therapy
Patient Intake and Medical History
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Email
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Your email
Email
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Your answer
First and Last Name
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Your answer
Address
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Your answer
Cell Phone
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Your answer
Date of Birth
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MM
/
DD
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YYYY
Sex
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Male
Female
Prefer not to say
Emergency Contact
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Your answer
Referral Source
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Your answer
Describe Chief Complaints
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Your answer
When did it start?
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MM
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DD
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YYYY
Where is your pain and what are you concerned about?
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Your answer
Is your pain constant or intermittent
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Constant
Intermittent
Rate your pain on a scale from 1 to 10 at worst
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0
1
2
3
4
5
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7
8
9
10
Your pain at best
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0
1
2
3
4
5
6
7
8
9
10
Your pain on average
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0
1
2
3
4
5
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7
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9
10
What triggers your pain, motions, positions, activities
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Your answer
What improves your pain, motions, positions, activities
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Your answer
What tests (x-ray, CT Scan, MRI, EMG) have you had recently, please elaborate
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Your answer
Please check if you have had or now have the following:
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High Blood Pressure
Heart Disease, Heart Attack, Pacemaker
Cancer
Rheumatoid Arthritis
Osteoarthritis
Diabetes
Fracture
Stroke or TIA
Infections Disease
Seizures/Epilepsy
COPD/Bronchitis/Asthma
Joint Replacements
Abdominal or Mid-Back Pain\
Open Wounds
Skin Condition
Metal Implants/Fragments
Osteoporosis
Vascular Problems
Neck or Back Problems
Fever and Chills
Unexplained Weight Loss
Pregnant Now
Required
Please give more detail to any if you marked yes to any of the above
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Your answer
Please list all previous surgeries
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Your answer
Allergies
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Your answer
Anything else you want to add? Goals, something you want us to know?
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Your answer
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