JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Patient Intake Form
Please answer all of the required items that are marked as "*" the best you can. You will have space later to write your own custom answers.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
First and Last Name:
*
Your answer
Age
*
Your answer
Are you right-handed or left handed
*
right-handed
left-handed
Required
Male of Female
*
male
female
Required
Current Status
*
student
homemaker
employee
laborer
athlete
retiree
unemployed
Other:
Required
What side is your main problem concern?
*
the right side
the left side
both sides
Where is your main problem concern?
*
low back
mid back
upper back
neck
shoulder
hip
thigh
knee
elbow
forearm
wrist
ankle
foot
vertigo or dizziness
Other:
Required
Are there other areas of complaints? (Other body regions, radiating pains, etc)
Your answer
Cause of Symptoms
*
a strain
a lifting strain
a strain while exercising
an athletic injury
a work injury
a motor vehicle accident
the current post-operative condition
performing unaccustomed activities
an unknown cause
Other:
Required
Approximate Date of Injury of Symptom Onset:
*
MM
/
DD
/
YYYY
If you had Surgery, what kind of surgery did you have and when? (If no surgery, write "none")
*
Your answer
Have you seen a Doctor for this or are you self-referred?
*
saw doctor
is self-referred
If you saw a Doctor, what is the Doctor's name?
Your answer
Have you had any tests for this condition
*
X-rays
MRIs
CT Scans
no diagnostic tests
Other:
Required
Approximate Date of Tests (leave blank if none)
MM
/
DD
/
YYYY
Results of Tests
not applicable
negative
positive
Clear selection
If the tests were positive, what were the results? (Leave blank if no tests or negative)
Your answer
What medications are you using for
THIS
condition? (Click all that apply)
*
tylenol
NSAIDS (Advil, Ibuprofen, Alleve)
muscle relaxers
pain medications/Opiods
unsure
no medications at this time
Other:
Required
Do you have a Medical History of
THIS
specific condition?
*
denies medical history of this complaint
has a medical history of this complaint
If you have a Medical History of this condition, please describe it (when, what treatment if any, recovery status):
Your answer
How would you rate your pain/symptoms at
REST
on a 0 - 10 scale?
(0 is none and 10 is the worst)
*
1
2
3
4
5
6
7
8
9
10
How would you rate your pain/symptoms at
WORST
on a 0 - 10 scale?
(0 is none and 10 is the worst)
*
0
1
2
3
4
5
6
7
8
9
10
How would you describe your pain?
*
achy
sharp
sore
stabbing
burning
Other:
Required
What worsens your symptoms?
*
activity
nothing that has been found
Other:
What improves your symptoms?
*
rest
nothing that has been found
Other:
Are your symptoms constant or does it come and go?
*
are constant
comes and goes
Are your symptoms worse in the morning, evenings, or both?
*
mornings
evenings
mornings and evenings
Since it started, are your symptoms:
*
better
worse
the same
Do you have the following neurological signs?
*
no complaints of numbness, tingling, and pins/needles
complaints of numbness
complaints of tingling
complaints of pins/needles
Other:
Required
If you have complaints of numbness, tingling, or pins/needles, where is it located?
Your answer
Do you have the following additional symptoms?
*
swelling
clicking
catching
locking
buckling
grating
headaches
fever
dizziness
falls
bowel/bladder difficutly
difficulty with vision
difficulty with swallowing
difficulty with speaking
none
Required
What treatments have you tried?
*
ice
heat
ointments/creams
no treatments
Other:
Required
Was your previous treatment helpful?
*
it has been helpful
it has not been helpful
is not applicable
Is your Past Medical History significant for this current problem? (Other medical problems)
*
past medical history is not significant
past medical is significant
Which of these following routine goals are the most important to you?
*
Sleeping thru the night (8 hours) with less pain
sit for 1-2 hours to allow for driving to work or for daily activities with less pain
bend forward to reach or lift objects as needed for self care and household activities with less pain,
safely bend over to lift household objects of 10-15 lbs 3-4x/day with less pain
safely reach overhead to lift cups and plates for meals at home 3x/day with less pain
perform work duties for 4-8 hours a day with less pain/difficulty
perform self-care tasks safely at home independently with less pain
perform fitness-related tasks 1-2 hours a day safely and with less pain
Which of the following ambulatory goals are most important to you?
*
move spine and extremities to WNL to allow for safe driving with less pain,
safely walk 1-2 hours for shopping or work related activities with less pain
walk normally and independently up to 1 hour on level surfaces without pain
stand normally up to 1 hour at a time as needed for housework without pain
Going up and down the stairs (10 steps) normally with less pain
Getting into or out of the bath safely with less pain
Please enter any other information regarding this current condition or past medical history that you feel the physical therapist should know including details on past medical history and other goals you may have: (if none, write none)
Your answer
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
