To help us assess the cause of your problem, please ...



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Date

Patient Name

Medical History Questionnaire

1. What problem or complaint brings you to Physical Therapy?

2. When did symptoms start? Did they come on suddenly or gradually? Circle.

3. Describe how they started?

Please indicate areas of symptoms on the diagrams to your right. 4. What is your pain intensity? Circle

0 1 2 3 4 5 6 7 8 9 10

Minimal Moderate EXTREME

5. Which of these words describe your discomfort? Check all that apply.

( Sharp ( Burning ( Intermittent

( Dull ( Numb/tingling ( Aching

( Constant ( Radiating ( Other Pain Agony

6. Which activities increase your discomfort/pain?

7. Which activities decrease your discomfort/pain?

8. What is the frequency of your discomfort/pain? ( constant ( intermittent

9. Does your discomfort/pain vary with the time of day? ( Yes ( No

what time of day is it the worst? ( Morning ( Afternoon ( Evening

what time of day is it the least? ( Morning ( Afternoon ( Evening

10. Do you have periods of time when you are completely free of discomfort/pain? ( Yes ( No When?

11. Does you discomfort/pain wake you at night? ( Yes ( No

12. Are you able to continue working? ( Yes ( No

13. Have you had diagnostics for this condition? ( X-rays ( Bone scan ( CAT scan ( MRI scan

( Nerve Conduction Studies ( Dexa Scan ( Blood tests

( Other?

Results

14. List all the meds you are currently taking for this or other problems/attach list

15. Are you currently pregnant? ( Yes ( No ( Not applicable

16. Have you had any falls in the past year? ( Yes ( No

17. a) Describe your regular recreational/exercise/sports activity prior to the onset of your symptoms.

State how many minutes of exercise and how many times per week

b) what modifications have you had to make?

18. Have you ever been diagnosed with any of the following conditions? Yes No Do you know if a blood relative has any of these diagnoses?

|Condition |Yes |No |Notes |

|Allergies | | | |

|Asthma | | | |

|Anaemia | | | |

|Autoimmume Disease (e.g. R/A, A/S, Reiter’s | | | |

|Disease, lupus). | | | |

|Blood clotting problems past or present (e.g. | | | |

|DVT ) | | | |

|Cancer | | | |

|Diabetes | | | |

|Emphysema/Bronchitis | | | |

|Epilepsy or seizures | | | |

|Fractures | | | |

|Heart Disease | | | |

|Heart Arrythmias | | | |

|Hypermobility Syndrome (e.g. Marfan’s or Ehlers| | | |

|Danlos Syndrome) | | | |

|Open Heart Surgery or Stent | | | |

|Hepatitis | | | |

|High Blood Pressure | | | |

|Recent Infection (including teeth) | | | |

|Joint Replacement | | | |

|Kidney Disease | | | |

|Multiple Sclerosis | | | |

|Muscular Dystrophy | | | |

|Osteoporosis | | | |

|Skin condition | | | |

|Stroke | | | |

|Thyroid problem | | | |

|Tuberculosis | | | |

19. Any known allergies to medications or other substances/foods?

20. Females: are you currently pregnant? ( Yes ( No

Do you get regular gynecological check ups? ( Yes ( No

21. Males: date of last prostate exam

22. All genders: Date of last colonoscopy

23. List all your surgeries pertaining to this condition or other medical conditions

24. How would you rate your general health? ( Poor ( Fair ( Good ( Excellent

25. What would you like to be able to do when your symptoms resolve?

26. Occupation ____________________________________________________________________________

27. Recreational Activities____________________________________________________________________

28. Does you problem interfere with your ability to do any recreational or work activities? ( Yes ( No

29. Please list in the test box below three activities that you would like to be able to do that your current condition makes difficult. Rate on scale of 0 = no pain, 10 = worst imaginable pain (e.g. unable to bend over to put on socks or tie shoes; increases pain to a 6/10).

|Activity |Level of Pain 0-10 |How long can you do the activity before needing to |

| | |stop? |

| | | |

| | | |

| | | |

Any other concerns you wish to mention that have not been listed?

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@ MoveMend

3221 Eastlake Avenue E

Suite 110,

Seattle WA 98102

Phone: 206 641 7733 fax: 206 641 3272

SUBJECTIVE INTAKE FORM

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