Intake Questionnaire
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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 (PCP) (First & Last Name)
*A referral for physical therapy from a qualified provider (physician, dentist, chiropractor, podiatrist, physician's assistant, or advanced nurse practitioner) is required to continue treatment beyond two weeks after your Evaluation.
PCP Facility Name & Location
PCP Fax Number
Specialist Provider (Name, Location)
How did you hear about LatitudePT? *
Who can we thank for referring you to LatitudePT?
The following is very important to 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? *
Are there any secondary problems?
Specifically, where are you experiencing symptoms? *
What words do you use to describe your symptoms? (i.e. dull, aching, sharp, stabbing, burning, numbness, tingling, weakness, tightness) *
When and how did your symptoms begin? *
Did you experience a trauma (physical or emotional) or a change in your routine around the time your symptoms began? *
"As a result, I am having difficulty with... (i.e. everyday activities, recreation, sports)." 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) *
Does anything else aggravate your symptoms? *
Have you found anything that 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 exercise and movement routine before your symptoms began (type, frequency, duration) *
Describe your current exercise and movement routine (type, frequency, duration) *
Describe 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, what is your daily fluid intake in liters? *
On average, how many alcoholic drinks do you have per week? *
One drink = 12 oz. beer, 5 oz. wine, or 1.5 oz. liquor
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? *
Are there any proactive strategies you use to deal with stress? *
CONNECT:
"Connect" pertains to your support structures and spheres of influence.
Please rate the strength of your social relationships: *
Medical History
What other treatments have you had for this problem? *
Required
Were those treatments helpful?
Does your medical history include any of the following conditions? Check all that apply. *
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 could 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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