Intake Questionnaire
* Required
Last Name, First Name
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Your answer
Phone #
*
Your answer
Email
*
Your answer
Address
*
Your answer
Date of Birth
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MM
/
DD
/
YYYY
Gender
*
Male
Female
Non-Binary
Other:
Marital Status
*
Married
Single
Widowed
Divorced
Other:
Occupation
*
Your answer
Emergency Contact (Name, Phone Number)
*
Your answer
Primary Care Provider (Name, Location)
*
Your answer
Specialist Provider (Name, Location)
Your answer
How did you hear about LatitudePT?
*
Friend
Family
Medical Provider
Google
Yelp
Instagram
Facebook
Other:
Who can we thank for referring you to LatitudePT?
Your answer
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?
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Your answer
Is there a secondary problem?
Your answer
Specifically, where are you experiencing symptoms?
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Your answer
How would you describe your symptoms? (i.e. dull, aching, sharp, stabbing, burning, numbness, tingling, weakness, tightness)
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Your answer
How and when did your symptoms begin?
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Your answer
Around the time your symptoms began did you experience a trauma of any kind (physical or emotional), or a change in your routine?
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Your answer
"As a result, I am having difficulty with ....(i.e. everyday activities, recreation, sports)." Please separate each activity/task on a new line.
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*Format: Task or Activity // Tolerance (i.e. minutes, reps)
Your answer
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
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0
1
2
3
4
5
6
7
8
9
10
At its best
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0
1
2
3
4
5
6
7
8
9
10
At present
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0
1
2
3
4
5
6
7
8
9
10
When are your symptoms the worst? (i.e. time of day, during an activity or movement)
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Your answer
When are your symptoms the best? (i.e. time of day, during an activity or movement)
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Your answer
What aggravates your symptoms?
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Your answer
What alleviates your symptoms?
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Your answer
Have you received diagnostic imaging for this problem (i.e. X-ray, MRI, CT scan)?
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Your answer
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)
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Your answer
Describe your movement routine since the onset of your symptoms (type, frequency, duration)
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Your answer
Comment on your workstation habits (i.e. Sit-stand desk? Frequency of breaks?)
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Your answer
FUEL:
FUEL pertains to how you sustain your body.
In your average meal, what percentage are fruits and vegetables?
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Your answer
On average, how often do you enjoy a home-cooked meal?
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Your answer
On average, what is your daily fluid intake in ounces? Please estimate.
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Your answer
On average, what is your weekly alcohol intake?
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Your answer
How would you rate your sugar intake?
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High
Medium
Low
RECOVER:
RECOVER pertains to sleep.
How many hours do you normally sleep per night?
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more than 7 hours
6-7 hours
less than 6 hours
Do you feel rested when you wake up in the morning?
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Yes
No
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?
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Your answer
CONNECT:
CONNECT pertains to your support structure and spheres of influence.
Who do you eat meals with?
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Your answer
Who do you exercise with?
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Your answer
Who do you go to for advice?
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Your answer
Please rate the strength of your social relationships:
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1
2
3
4
5
6
7
8
9
10
Medical History
What other treatments have you had for this problem?
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Massage
Bodywork
Physical Therapy
Myofascial Release
Chiropractic
Surgery
Injections
None
Other:
Required
Were those treatments helpful?
Your answer
Do you have a history of any of the following medical conditions?
*
Surgery
Broken Bones or Fractures
Trauma/Injuries (physical or emotional)
Headaches
Migraines
Arthritis
Osteoporosis
Pregnancy
Autoimmune Disease
Rheumatic Fever
Diabetes
Lung Disease
Sudden Weight Change
Blackouts
Varicose Veins
Neurological Problems
Epilepsy/Seizures
Stroke
Heart Murmur
Malignancy (Cancer)
Metal Implants
High Blood Pressure
Circulatory Problems
Heart Disease
Pacemaker
Liver Disease
Kidney Disease
None of the above
Other:
Required
Please provide details for the boxes checked above including the date(s) of occurrence.
Your answer
List your current medications and supplements. Please separate each on a new line.
*
*Format: Medication // For treatment of... // Dose // Effectiveness
Your answer
Do you smoke tobacco?
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Yes
No
Is there a chance you may be pregnant at this time?
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Yes
No
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.
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*Format: Task or Activity // Duration or How Often // By When
Your answer
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