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Questionnaire
First Name
Email
Last Name
Phone
Full Address
Date of Birth
Height
Age
Weight
Answer the following questions:
What injury or condition brings you to physical therapy?
When did your injury, symptoms or surgry occur?
Are you in pain today?
Yes
No
Rate your pain on a scale of 0-10 where 0 is no pain and 10 is pain that prevents you from all basic activities and requires strong pain medication
At the present time, how would you rate your overall health?
Excellent
Good
Fair
Poor
What normal daily activities are you having difficulty doing, due to your symptoms?
What have you done to address your symptoms up to this point? (could be self- treatment or through other providers)
Do you have any other joints that give you issues?
What are you hoping to achieve with physical therapy treatment?
Have you had any of the following tests related to this condition: (if yes, check all that apply)
X-Ray
Bone Density Test
EMG
MRI
Bone Scan
Blood Test
CT-Scan
Othr
Please list any other orthopedic conditions or surgery you have had and the date:
Do you have a pacemaker/defibrillator?
Yes
No
Do you have any allergies?
Yes
No
Do you smoke cigarettes?
Yes
No
Are you pregnant or think you could be pregnant?
Yes
No
What allergies?
How much?
Have you experienced any falls in the past 12 months?
Yes
No
How many times and details:
Do you take any medications?
Yes
No
Please list any medications, both prescribed and over the counter, as well as supplements you are taking
Have you recently experienced any of the following? Check off those you have.
Fever/Chills/Sweats
Repeated Infections
Recent weight loss /gain
Numbness / tingling
Weakness in the arms or legs
Chest pain / heart palpitations
Shortness of breath
Dizziness or vertigo
Bowel/ bladder problems
Nausea / vomiting
Chicken Pox / shingles
Joint pain
Headaches
Blurred vision / visual changes
Cough
Sore throat
Anxiety
Depression
Difficulty sleeping
Hot flashes
Unexplained Fatigue
Have you ever been diagnosed with any of the following conditions?
High blood pressure
Heart problems ( angina, A fib, coronary disease)
Lung problems / Tuberculosis
Infectious disease (HIV, MRSA, Co-Vid 19)
Cancer
Kidney Disease
Liver Disease
Thyroid problem
Diabetes
Stroke
Parkinson’s Disease
Blood disorders
Head injury
Seizure disorders or epilepsy
Dementia / Alzheimer’s
Neurological problems
Osteoarthritis
Auto immune conditions ( RA, Lupus, etc)
Visual / hearing problems
Gastrointestinal problems
Gynecological problems
Sleep apnea
Your Signature
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