Intake Questionnaire
Last Name, First Name *
Phone # *
Email *
Address *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Marital Status *
Occupation *
Emergency Contact (Name, Phone Number) *
Primary Care Provider (Name, Location) *
Specialist Provider (Name, Location)
How did you hear about LatitudePT? *
Who can we thank for referring you to LatitudePT?
THE FOLLOWING IS VERY IMPORTANT IN OUR EVALUATION PROCESS. Do your best to provide us with a clear picture of your CURRENT symptoms and functional status.
What is the primary problem you are dealing with? *
Is there a secondary problem?
Specifically, where are you experiencing symptoms? *
How would you describe your symptoms? (i.e. dull, aching, sharp, stabbing, burning, numbness, tingling, weakness, tightness) *
How and when did your symptoms begin? *
Around the time your symptoms began did you experience a trauma of any kind (physical or emotional), or a change in your routine? *
"As a result, I am having difficulty with ....(i.e. everyday activities, recreation, sports)." Please separate each activity/task on a new line. *
*Format: Task or Activity // Tolerance (i.e. minutes, reps)
Symptom Scale
Please rate your symptoms based upon the last 48 hours using a 0-10 scale. 0 is nothing, while 10 is the worst imaginable.
At its worst *
At its best *
At present *
When are your symptoms the worst? (i.e. time of day, during an activity or movement) *
When are your symptoms the best? (i.e. time of day, during an activity or movement) *
What aggravates your symptoms? *
What alleviates your symptoms? *
Have you received diagnostic imaging for this problem (i.e. X-ray, MRI, CT scan)? *
MOVE:
MOVE pertains to your movement routine including exercise or other movement you engage in regularly.
Describe your movement routine prior to the onset of your symptoms (type, frequency, duration) *
Describe your movement routine since the onset of your symptoms (type, frequency, duration) *
Comment on your workstation habits (i.e. Sit-stand desk? Frequency of breaks?) *
FUEL:
FUEL pertains to how you sustain your body.
In your average meal, what percentage are fruits and vegetables? *
On average, how often do you enjoy a home-cooked meal? *
On average, what is your daily fluid intake in ounces? Please estimate. *
On average, what is your weekly alcohol intake? *
How would you rate your sugar intake? *
RECOVER:
RECOVER pertains to sleep.
How many hours do you normally sleep per night? *
Do you feel rested when you wake up in the morning? *
ENDURE:
ENDURE pertains to our response to adversity.
Are there any behaviors you engage in when stressed that you think could be problematic? Do you have any proactive strategies you use when stressed? *
CONNECT:
CONNECT pertains to your support structure and spheres of influence.
Who do you eat meals with? *
Who do you exercise with? *
Who do you go to for advice? *
Please rate the strength of your social relationships: *
Medical History
What other treatments have you had for this problem? *
Required
Were those treatments helpful?
Do you have a history of any of the following medical conditions? *
Required
Please provide details for the boxes checked above including the date(s) of occurrence.
List your current medications and supplements. Please separate each on a new line. *
*Format: Medication // For treatment of... // Dose // Effectiveness
Do you smoke tobacco? *
Is there a chance you may be pregnant at this time? *
Goals: List the activities that you would like to be able to do after completing physical therapy. Please separate each goal on a new line. *
*Format: Task or Activity // Duration or How Often // By When
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