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)
*Texas is a Direct Access state, meaning a referral for physical therapy is NOT required to start PT, however, we are required to get one in order to continue after two weeks from your first visit. This is a requirement of our state board and it has nothing to do with insurance. A referral can come from a physician, nurse practitioner, podiatrist, dentist, or chiropractor. Often your may not need to go in for an office visit, however every provider is different. Referrals can be sent to our fax at (855) 574-0792 or to Dr. Gumbs' encrypted email inbox: chris@latitudept.com.
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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