New Patient Paperwork
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Email *
Name *
What is your birthday? *
What is your home address? Please include city and zip code *
Please list name & phone number of emergency contact *
Reason for therapy? *
Date of onset? *
Treatment received so far? (ex injection, chiropractor, etc.) Please write n/a if no treatment has been received. *
Please list tests performed for this problem. (ex MRI, x-ray)
Have you participated in PT during this calendar year? *
Have you had this problem before? If so, how long until you felt better?
Could you be or are you currently pregnant? *
Have you RECENTLY noted any of the following? (check all the apply) *
Required
Have you EVER been diagnosed with any of the following conditions (check all that apply)? *
Required
Has anyone in your immediate family (parents, brothers, sisters) EVER been diagnosed with any of the following conditions (check all that apply)? *
Required
During the past month have you been feeling down, depressed or hopeless? *
During the past month have you been bothered by having little interest or pleasure in doing things? *
If yes, is this something with which you would like help? *
Please list any surgeries or other conditions for which you have been hospitalized, including dates. Please write n/a if you have not had any surgeries. *
Please list any medications you are taking and specify condition. Please write n/a if you are not taking any medications. *
Have you ever taken steroid medications for any medical conditions? *
Have you ever taken blood thinning or anticoagulant medications for any medical conditions? *
Using the 0 to 10 the scale, with 0 being “no pain” and 10 being the “worst pain imaginable” please describe your current level of pain while completing this survey: *
Aggravating Factors: Identify up to 3 important positions or activities that make your symptoms worse: *
Easing Factors: Identify up to 3 important positions or activities that make your symptoms better: *
My pain/symptoms increase with walking or stair climbing and are relieved with rest? *
My symptoms currently: *
My symptoms are currently: *
Are you having trouble falling or staying asleep? *
When are your symptoms the worst? *
When are your symptoms the best? *
I should not do physical activities that might make my pain worse: *
Does coughing, sneezing or taking a deep breath make your pain feel worse? *
Does bending, sitting, lifting, twisting or turning over in bed make your pain feel worse? *
Has there been any change in your bowel habit since the start of your symptoms? *
Does eating certain foods make your pain feel worse? *
At the present time, would you say your health is: *
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