Injury History
Fill this out at least 2 days prior to your first appointment. Your paperwork is complete when you hit Submit.
Full Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Date of Injury / Date Symptoms Began *
MM
/
DD
/
YYYY
Cause of Injury *
Your answer
If Surgery Occurred on the Injured Area, List Date and Type of Surgery
Your answer
Location of Symptoms (Included Right, Left, And/Or Bilateral) *
Your answer
Type of Symptoms (Check All That Apply) *
Required
What has Changed In Symptoms Since They Began? *
Your answer
Stability of Symptoms *
Symptoms/Pain Increases With *
Your answer
Symptoms/Pain Decreases With *
Your answer
Medical History (Check All the Apply & Scroll All the Way to the Right) *
Osteoporosis
Heart Disease
Asthma
Seizures
Cancer
Diabetes
Multiple Sclerosis
High Blood Pressure
Rheumatoid Arthritis
Cerebral Vascular Accident
Alzheimer's
Lupus
Fibromyalgia
No Health Issues
Current Issues
List Any Previous Surgeries & Dates
Your answer
Other Current/Previous Injuries
Your answer
List Date of Previous Pregnancies (if applicable)
Your answer
Diagnostic Tests & Results
Your answer
Current Medication & Dosages *
Your answer
Occupation
Your answer
Goal with Physical Therapy *
Your answer
Pain Level at Worst (In the last week) *
No Pain
Emergency Room Pain
Pain Level at Best (In the last week) *
No Pain
Emergency Room Pain
List Activities that Are Affected by your Symptoms & your Current Limitations in those Activities (ex. walking > 10 min, sitting >15min, wake up 2x/night, Side Angle Pose: pain) *
Your answer
List your Previous Abilities in those Activities (ex. walking > 60 min, sitting unlimited, sleep through the night, Side Angle Pose: no pain) *
Your answer
Choose Category that Most of Your Limitations Are In *
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