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Fillmore PT Patient Information
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Name
*
Your answer
Street Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zipcode
*
Your answer
Date of birth
*
Your answer
Landline / Home phone number
Your answer
Cell phone number
Your answer
Is it ok to text your cell phone for appt reminders?
Yes
No
Clear selection
Which form of communication do you prefer from us?
Text
Phone Call / Voicemail
Clear selection
Email address
Your answer
Is it ok to email you with information related to your PT?
Yes
No
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Referring Dr
*
Your answer
Diagnosis (If known)
Your answer
Insurance Company (card will be copied at appt)
Your answer
Please describe your current Complaint or limitation
*
Your answer
Describe how and when the problem began
*
Your answer
Did you have imaging (x-ray, MRI, CT scan) for this problem? If so, where?
*
Your answer
If you have had imaging, what were the results?
Your answer
Did you have surgery for this problem? If so, when?
*
Your answer
Any other surgeries? (Please list)
*
Your answer
Please describe the nature of your pain
*
Sharp
Dull/ Ache
Throbbing
Numbness
Shooting
Burning
Tingling
Required
Is your pain
Constant (76-100%)
Frequent (51-75%)
Occassional (26-50%)
Intermittent (25% or less)
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Rate your pain at rest (10 being the worst)
0
1
2
3
4
5
6
7
8
9
10
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Rate your pain with movement (10 being the worst)
0
1
2
3
4
5
6
7
8
9
10
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What makes the pain worse?
Your answer
What makes the pain better?
Your answer
What time of day are your symptoms worst
Morning
Afternoon
Evening
All day the same
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Have you ever been treated for this problem before?
Yes
No
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What is your occupation?
Your answer
Has your work status changed as a result of this problem?
Yes
No
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Do you have an open workers' comp case pertaining to this problem?
Yes
No
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What are your SPECIFIC goals for therapy? Please list several if applicable. (Specify activities you could do previously. Examples: "walk up a flight of stairs without pain" or "sleep through the night without pain waking me" or "walk more confidently without fear of falling")
Your answer
Please tell us any current health issues we need to be aware of.
Your answer
Please tell us any pertinent health history or surgical procedures you have had.
*
Your answer
Please check any medical issues below that you have had or presently have.
Present
Past
High Blood Pressure
Angina
Heart Attack
Pacemaker
Stroke
Asthma
HIV/ AiDS
Cancer (anywhere)
Tumor
Systemic Lupus
Hepatitis
Epilepsy
Diabetes
Rheumatoid Arthritis
Arthritis
Pregnancy
Tobacco
Drug or Alcohol Dependence
Present
Past
High Blood Pressure
Angina
Heart Attack
Pacemaker
Stroke
Asthma
HIV/ AiDS
Cancer (anywhere)
Tumor
Systemic Lupus
Hepatitis
Epilepsy
Diabetes
Rheumatoid Arthritis
Arthritis
Pregnancy
Tobacco
Drug or Alcohol Dependence
Medication list (or bring with your to your appt)
Your answer
Do you have a latex allergy (or other allergies)? Please list
Your answer
Do you have an upcoming Dr appt? If so, when?
*
Your answer
Please list individuals with whom you give us permission to discuss your health records.
*
Your answer
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