JAMES CREPS PHYSICAL THERAPY
General Medical Questionnaire
Name: _________________________________ Birthdate: _____________ Age: ______ Date of Eval: ____________
Height: _____ ft. _____ in. Weight: _________ lb. Phone: ________________________
Personal Medical History: Yes No Yes No Yes No
|Are you pregnant? |
List any prior surgical procedures___________________________________________________________________________
List relevant imaging (X-ray, MRI, etc.): ______________________________________________________________________
List allergies: ___________________________________________________________________________________________
When did your symptoms begin/injury occur? __________________________________________________________________
What are you having difficulty doing because of your symptoms/injury? _____________________________________________
Describe occupation or note if retired: _________________________________________Are you presently working? Yes No
What is the highest grade/degree you have completed? _________________________________________________________
Is this a work or auto related injury? No Yes Explain: _________________________________________________________
Have you had any change in your diet/eating habits? No Yes Explain: ___________________________________________
Do you have any cultural/religious beliefs that may affect your treatment? No Yes Explain: ___________________________
Do you have any financial or transportation concerns that will affect your participation in treatment? No Yes Explain: _______
_____________________________________________________________________________________________________
What are your therapy goals (i.e., what would you like to get out of therapy?) ________________________________________
Patient Pain Index
|How often does pain occur? |If your current condition is causing you pain, please put an “X” on drawing where you feel pain. |
|Constant |[pic] [pic] |
|Comes during activity |Front View Back View |
|if so, what activity: _______________________ | |
|Occurs randomly | |
|Does Pain affect your sleep? | |
|Wakes from sleep | |
|Prevents sleep | |
|Better after sleep | |
|How you would describe your pain? | |
|Sharp | |
|Dull | |
|Radiating | |
|Throbbing | |
|Burning | |
|Numbness | |
Please place an “X” on the SCALE below from 0 to 10 which best describes the amount of pain you are experiencing.
0 1 2 3 4 5 6 7 8 9 10
No Pain Moderate Pain Severe Pain
Please check the boxes for answers to the following questions:
| | | | |HOW WOULD YOU |
|PHYSICAL/COGNITIVE |LANGUAGE |YOUR MOTIVATION |PREFERRED |LIKE YOUR HOME |
|LIMITATIONS |BARRIERS |TO LEARN |LEARNING METHOD |EXERCISE PROGRAM |
|None |( None |Eager |Hearing |Demonstration Only |
|Vision |( Unable to speak/understand |Cooperative |Reading |Written Handout |
|Hearing |English |Skeptical |Visual Demonstration |Both |
|Speech |( Unable to read English |Unsure |No Preference | |
|Acute Illness | | | | |
|Dementia | | | | |
Patient’s Signature: __________________________________________________ Date ____________________________
|This portion to be completed by the physical therapist: |
|Does the patient require a social work referral? |Yes |No |Why: _____________________ |
|Is the patient aware of diagnosis? |Yes |No | |
|What is prognosis? |Poor |Fair |Good |Excellent |
|Is patient aware of prognosis? |Yes |No | |
| | |
|Physical Therapist’s Signature: ________________________________________________________ |Date ___________________________________ |
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