Physiotherapy Intake
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Other
Health Information
Was there an incident that brought on your current problem/injury?
Yes
No
For how long have you been experiencing this problem?
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0
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Using the line scale provided below, rate your level of pain over the last 24 hours.
1
2
3
4
5
6
7
8
9
10
No Pain
Severe Pain
Is your pain:
Off and On
Constant, 24 hours a day
Is your pain:
Getting better
Getting worse
Staying the same
At what time of day does it seem to be at its worst?
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0
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Describe anything at work or daily activities that affect your injury/pain levels (eg. Prolonged sitting, physical demands, stress)
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0
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Are there any sports, activities or hobbies that you enjoy doing?
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0
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Conditions
If you have been treated for any of the following conditions please indicate with a check mark:
MUSCULOSKELETAL
Sprain/Strain
Joint Replacement
Whiplash
Gout
Arthritis (OA, RA)
Fracture, if yes where is the location?
Characters:
0
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CARDIOVASCULAR SYSTEM
Heart Disease
High Blood Pressure
Low Blood Pressure
Blood Clots
Circulatory Issues
Varicose Veins
NERVOUS SYSTEM
Fainting/Dizziness
Seizures/Epilepsy
Neurological Disorder
SKIN
Eczema/Dermititis
Psoriasis
Fungal Infection
Other
Characters:
0
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GASTROINTESTINAL SYSTEM
Hemorrhoids
Abdominal Pain
Digestive Problems
IBS
OTHER
Kidney Disorder
Liver Disorder
Thyroid Problems
Tuberculosis
Diabetes Type l
Diabetes Type II
Cancer
Anemia
Hemophilia
HIV/AIDS
Hepatitis
Headaches/Migraines
Depression
Anxiety
Do you have any other information that would be beneficial to YOUR treatment?
Medications
Medication
Add Another Medication
Injuries
Injury
Add Another Injury
Surgeries
Surgery
Add Another Surgery
For Auto Claims Only
Is your condition the result of an auto accident that involves lawyers or car insurance companies?
yes
no
If you answered yes to the above question, What is the Claim number?
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0
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What is the name of your lawyer if you have one?
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0
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What is your lawyer's phone number?
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What is your lawyer's email address?
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0
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What is your lawyers fax number?
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What is the name of your claim Specialist?
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0
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What is your claim specialist's phone number?
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What is your claim specialist's email?
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0
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What is your claim specialist's fax number?
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