INTAKE QUESTIONNAIRE Name:__________________________________________________ Date:_______________________ Date of Birth: ___________ Email: ________________________ Phone: _____________________ Referral from: ______________________________________________________________________ Primary physician: __________________________________________________________________ Reason for referral: _________________________________________________________________ Date of onset: __________________________________________ What function(s) do you hope to improve/change by coming to physical therapy? What are your physical goals? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
Medical History If you have had surgery for this or a different diagnosis, please complete the following for each: Surgery type and date: ______________________________ Improvement?_________________ Surgery type and date: ______________________________ Improvement?_________________ Surgery type and date: ______________________________ Improvement?_________________ Surgery type and date: ______________________________ Improvement? ________________
Art Sansone PT LLC 3736 Bee Caves Rd, Suite 1-216, W Lake Hills TX 78746
[email protected] TELEPHONE: 202 669-7044
Prior physical injury history: Include major work or non-work related injuries (fractures, major sprains/strains) and their dates: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Please check all that apply to you: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Osteoarthritis ___ Dizziness/vertigo/fainting Rheumatoid arthritis ___ Gastrointestinal issues (IBS, Crohn’s) Osteoporosis/Osteopenia ___ Stroke Pregnant/attempting pregnancy ___ Using blood thinners Heart problems/heart disease ___ Hepatitis A/B/C Severe headaches ___ Circulation problems/blood clots Recurrent muscle/joint pain ___ Diabetes Type 1/Type 2 Cancer_______________________ ___ Chest pain/angina Lyme disease/tick-related illness ___ Kidney disease/stones Multiple sclerosis ___ Bronchitis/emphysema/pneumonia Fibromyalgia ___ Thyroid condition Skin condition________________ ___ Asthma Allergies _____________________ ___ Epilepsy Pacemaker ___ Prostate issues Blood pressure- High/Low ___ Gout Poor balance or recent falls ___ Depression Endometriosis ___ Nerve injury Tuberculosis ___ HIV/AIDS GERD/Heartburn ___ Menstrual issues Chemical dependency (alcohol/drugs) ___ Abdominal pain/bloating Bleeding disorders ___ Psychological______________________ Other___________________________________________________________________________
Please list any medications you are currently taking, type, dosage and how long you have been taking it: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
Art Sansone PT LLC 3736 Bee Caves Rd, Suite 1-216, W Lake Hills TX 78746
[email protected] TELEPHONE: 202 669-7044
Current Condition Where is/are your pain/symptoms (i.e., location and type)? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ When did this current episode begin? Was the onset gradual or sudden? _____________________________________________________________________________________ _____________________________________________________________________________________ How did the episode of pain/symptoms begin? If your pain/symptoms are due to an injury, briefly describe the events leading to the injury. _____________________________________________________________________________________ _____________________________________________________________________________________ Have you had prior episodes of the pain/problem?
___Yes
___No
If yes, how many episodes have you had? ______________________________________ When did the first episode begin?______________________________________________ Is this episode worse than the prior episode(s)? ___Yes ___No What caused the prior episode(s)? _____________________________________________ _____________________________________________________________________________________ Date/outcome of any medical tests/special tests performed with regard to your current issue: X-rays: ______________________________________________________________________ MRI/CT scan: ________________________________________________________________ EMG: ________________________________________________________________________ Steroid/Other injection: ______________________________________________________ Other: _______________________________________________________________________ Are you receiving any current therapy (i.e., physical therapy/chiropractic/massage/ exercise, etc.) for your current condition? If so, please indicate type and effectiveness: _____________________________________________________________________________________ _____________________________________________________________________________________
Art Sansone PT LLC 3736 Bee Caves Rd, Suite 1-216, W Lake Hills TX 78746
[email protected] TELEPHONE: 202 669-7044
Please check the activities below that affect your pain/problem: Standing Sitting Walking Driving Bending forward Bending backward Lying on stomach Lying on back Reaching overhead Reaching behind back Lifting > 5lbs Pushing/Pulling > 5lbs Gripping with hand Writing Typing Using computer mouse Squatting Kneeling Coughing Sneezing Sleeping Other _______________________________
Better ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____
Worse ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____
No change ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____
On a 0 to 10 pain scale, with “0” being “no pain” and “10” being the “greatest level of pain”: What number represents your WORST level of pain? 0
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10
What number represents your LEAST level of pain? 0
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What number represents your level of pain AT THIS TIME? 0
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Signature ____________________________________________ Date ________________________
Art Sansone PT LLC 3736 Bee Caves Rd, Suite 1-216, W Lake Hills TX 78746
[email protected] TELEPHONE: 202 669-7044
