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What I Treat
Date of Birth
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?
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?
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)
Bone Density Test
Please list any other orthopedic conditions or surgery you have had and the date:
Do you have a pacemaker/defibrillator?
Do you have any allergies?
Do you smoke cigarettes?
Are you pregnant or think you could be pregnant?
Have you experienced any falls in the past 12 months?
How many times and details:
Do you take any medications?
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.
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
Blurred vision / visual changes
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)
Seizure disorders or epilepsy
Dementia / Alzheimer’s
Auto immune conditions ( RA, Lupus, etc)
Visual / hearing problems
We'll get in touch with you soon!
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