Medical Intake Form

PAGE 1

Existing Client NoYes

Your First name*

Your Middle name

Your Last name*

Your email*

ID#

Address

Telephone (H)

Telephone (W)

Telephone (C)

Date of Birth

Employer

Next of Kin

Next of Kin Telephone

Next of Kin Relation

Marital Status singlemarrieddivorcedwidowed

Leisure activities, including exercise routines:

Occupation, including activities that comprise your workday

Height (ft)

Weight (Pounds)

Are you on a work restriction from your doctor? Please Select a ValueNOYES

Is this a medical legal case? Please Select a ValueNOYES

Are you latex or tape sensitive? Please Select a ValueNOYES

Do you smoke? Please Select a ValueNOYES

Do you have a pacemaker or any other implanted device? Please Select a ValueNOYES

If you have a pacemaker Please Describe Please Select a ValueNOYES

FOR WOMEN: Are you currently pregnant or think you might be pregnant? Please Select a ValueNOYES

ALLERGIES: List any medication(s) or food you are allergic to:

PAGE 2

Have you RECENTLY noted any of the following (check all that apply)?
FatigueNumbness or TinglingConstipationFever/Chills/SweatsMuscle WeaknessDiarrheaNausea/VomitingDizziness/LightheadednessShortness of breathWeight Loss/GainHeartburn/IndigestionFaintingDifficulty maintaining balance while walkingDifficulty SwallowingCoughChanges in bowel or bladder functionFallsHeadachesSkin Changes

Body Chart:
Please mark the areas where you
feel symptoms on the chart to the right with
the following symbols to describe your symptoms:
 Shooting/sharp pain
 Dull/aching pain
||| Numbness
= Tingling

Please mark the areas where you feel symptoms (Dull/aching pain, Numbness, Tingling)

My symptoms currently:
Come and goAre ConstantAre constant, but change with activity

What date (roughly) did your present symptoms start?

What do you think caused your symptoms?

My symptoms are currently: Please Select a ValueGetting BetterGetting WorseStaying about the same

I should not do physical activities that might make my pain worse: Please Select a ValueDisagreeUnsureAgree

Treatment received so far for this problem (chiropractic, injections, etc)

PAGE 3

Please list special tests performed for this problem (x-ray, MRI, labs, etc)

Have you ever had this problem before: Please Select a ValueNOYES

When

Treatment rec’d

How long did it take for you to feel better?

Aggravating Factors: Identify up to 3 important positions or activities that make your symptoms worse:

Easing Factors: Identify up to 3 important positions or activities that make your symptoms better:

How are you currently able to sleep at night due to your symptoms? Please Select a ValueNo problem sleeping Difficulty falling asleepAwakened by painSleep only with medication

When are your symptoms worst? Please Select a ValueMorningAfternoonEveningNightAfter exercise

When are your symptoms the best? Please Select a ValueMorningAfternoonEveningNightAfter exercise

Using the 0 to 10 scale, with 0 being “no pain” and 10 being the “worst pain imaginable” please describe:

Your current level of pain while completing this survey: 0 No Pain - 10 Worst Pain Imaginable Please Select a Value012345678910

The best your pain has been during the past 24 hours: 0 No Pain - 10 Worst Pain Imaginable Please Select a Value012345678910

The worst your pain has been during the past 24 hours: 0 No Pain - 10 Worst Pain Imaginable Please Select a Value012345678910

Please list any medications you are currently taking (INCLUDING pills, injections, herbal supplements and/or skin patches):

Have you ever taken steroid medications for any medical conditions? Please Select a ValueNOYES

Have you ever taken blood thinning or anticoagulant medications for any medical conditions? Please Select a ValueNOYES

Please list any surgeries or other conditions for which you have been hospitalized, including dates:

Page 4

Have you EVER been diagnosed with any of the following conditions (check all that apply)?
CancerDepressionThyroid problemsHeart ProblemsLung ProblemsDiabetesChest Pain/Angina TuberculosisOsteoporosisHigh Blood Pressure AsthmaMultiple SclerosisCirculation ProblemsRheumatoid ArthritisEpilepsyBlood ClotsOther Arthritic ConditionEye Problem/InfectionStrokeBladder/Urinary Tract InfectionUlcersAnemiaKidney Problem/InfectionLiver ProblemsBone or Joint InfectionSexually Transmitted Disease/HIVHepatitisChemical Dependency (i.e., alcoholism)Pelvic Inflammatory DiseasePneumonia

Has anyone in your immediate family (parents, brothers, sisters) EVER been diagnosed with any of the following conditions (check all that apply)?
CancerDiabetesTuberculosisHeart ProblemsStrokeThyroid ProblemsHigh Blood PressureDepressionBlood Clots

During the past month have you been feeling down, depressed or hopeless? Please Select a ValueNOYES

During the past month have you been bothered by having little interest or pleasure in doing things? Please Select a ValueNOYES

Is this something with which you would like help? Please Select a ValueNOYESYES, BUT NOT TODAY

Do you ever feel unsafe at home or has anyone hit you or tried to injure you in any way? Please Select a ValueNOYES

What are your goals for physical therapy?

Referring Doctor:

Date of referral:

Are there any other problems you would like to discuss with your therapist?

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