Creamer Physical Therapy New Patient Form
Please fill out all the required questions and submit before your initial evaluation.
First Name
Your answer
Last Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
PATIENT INFORMATION
Home Address
Street, City, State, ZIP
Your answer
Home Phone Number
ex: xxx-xxx-xxxx
Your answer
Cellular Phone Number
ex: xxx-xxx-xxxx
Your answer
Best Number to Contact
Email Address (used for appointment reminders)
ex: johndoe@gmail.com (type none if no email)
Your answer
Gender
Emergency Contact
ex: John Doe
Your answer
Emergency Contact Relationship
ex: Father
Your answer
Emergency Contact Phone Number
ex: xxx-xxx-xxxx
Your answer
Referring Doctor
If none, please type none
Your answer
Employer
Your answer
Employer Phone Number
ex: xxx-xxx-xxxx
Your answer
Are you having HOME HEALTH currently or in the last month?
MEDICARE PATIENTS ONLY
Have you had any PHYSICAL or SPEECH therapy this year?
MEDICARE PATIENTS ONLY
Due to Car Accident?
IF due to car accident, name of auto insurance
Your answer
IF due to car accident, when was date of accident?
MM
/
DD
/
YYYY
IF due to car accident, do you have an attorney?
IF yes to attorney, list attorney name and phone number
ex: John Doe, xxx-xxx-xxxx
Your answer
MEDICAL HISTORY
Current complaint/reason for coming in
ex: low back pain, post-op hip replacement, RTC tear, etc
Your answer
What is the date of injury or when did your problem first start?
MM
/
DD
/
YYYY
Prior Medical History (muscle/joints)
ex: chronic low back pain, hip replacement
Your answer
Please list any allergies:
ex: latex, pollen
Your answer
Please list ALL medications you are presently taking (name AND dosage)
if none, type none
Your answer
List all prior surgeries
Your answer
Have you had any of the following problems?
Check all that apply (check none of above if none)
Required
Have you had physical therapy before for this condition?
PAIN ASSESSMENT
Please complete if pain is a symptom of the problem which you are seeking physical therapy
Where is your pain?
ex: right knee, left shoulder, low back, etc
Your answer
What caused the pain?
ex: a fall, lifting weights, running
Your answer
Check all the words below that describe your pain
Required
Check off all of the following that causes you pain
How is the pain changing?
What time of day/activity causes the pain to worsen?
Check all that apply
Which of the following aggravates the pain?
Check all that apply
Is there anything that helps relieve the pain?
Check all that apply
On a scale of 0-10, rate the level of pain at its worst
No pain
Worst pain experienced
On a scale of 0-10, rate the level of pain at its best
No pain
Worst pain experienced
On a scale of 0-10, rate your average level of pain
No pain
Worst pain experienced
How frequent is the pain?
FUNCTIONAL ACTIVITY INDEX
Functional Activity Index: EXERCISE
Functional Activity Index: SLEEP
Functional Activity Index: SITTING
Functional Activity Index: STANDING
Functional Activity Index: PERSONAL CARE
Functional Activity Index: WALKING
Functional Activity Index: LIFTING
Functional Activity Index: SOCIAL LIFE
Functional Activity Index: CHANGING DEGREE OF PAIN
Functional Activity Index: TRAVELING
PATIENT GOALS
Check all that apply
Required
ELECTRONIC SIGNATURE
Please sign to confirm all information provided above is accurate.
Please type full name below to electronically sign that the information you have provided is accurate and up to date.
Your answer
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