Medical Intake Form - Walker Physical Therapy And Sport Injury Center printable pdf download

Medical Intake Form - Walker Physical Therapy And Sport Injury Center

MEDICAL INTAKE FORM

Thank you for choosing Walker Physical Therapy and Sport Injury Center.

Please take your time while answering the following questions as it will help us give you the best care possible.

PATIENT HISTORY

Patient Name: _______________________________________

Age:______________

Diagnosis:____________________________

Referring Physician:_______________________________ Recent Surgery and Dates:____________________________________________

Medications:

1. ____________________________________ Dosage: ________________________ Frequency: ____________________

2. ____________________________________ Dosage: ________________________ Frequency: ____________________

3. ____________________________________ Dosage: ________________________ Frequency: ____________________

4. ____________________________________ Dosage: ________________________ Frequency: ____________________

Other Medications/Vitamins: ___________________________________________________________________________________________

CURRENT CONDITION

Date of injury:

Mechanism of injury:

Describe your chief complaint / concern:

Identify any position / activity that eases your symptoms:

Identify any position / activity that aggravates your symptoms:

What is your goal with physical therapy:

BODY CHART / PAIN LEVEL

Mark areas where you feel symptoms. Use the symbols to describe

your symptoms and rate the pain 0-10 with 0 as no pain and 10

as so intense you would need to go to the emergency room.

T = Tingling

N = Numbness

P = Pain

S = Shooting / Sharp pain

Do your symptoms (check one:)

o Come and go

o Constant

o Change with activity

Does your pain / symptoms subside while resting at night? o Yes

o No

Medical Intake Form - Walker Physical Therapy And Sport Injury Center