New Patient Form for Physical Therapy

Back In Motion Integrative Therapy

New Patient Information Sheet

Welcome to our practice!

Please help us serve you better by taking a few minutes to provide the following information.

Name:_______________________________________________________________________ Today's Date:________________________________

Last name First Name

Address:______________________________________________________________________________________________________________________

Street Apt# City State Zip

Phone Number: Cell (______)____________________ Home (______)____________________ Work (______)____________________

Date of Birth:__________________ Age:____________________ Gender: M F

E-mail:___________________________________________________

Occupation:_______________________________________________ Employer:__________________________ Marital Status: M S W D

Emergency Contact: Name:______________________________ Phone: (______)____________________

Primary Care Physician:____________________________________ Date of next visit: _________________

Specialist Physician: _______________________________________ Date of next visit: _________________

How did you hear about our practice? ____________________________________________________________

Did anyone refer you? __________ Name: __________________________________________________________

The following is very important in our evaluation process.

Please fill out these forms as specifically as possible to provide us with a clear picture of your

present pain and functional status.

What is the primary complaint that brings you in today?

Secondary complaint?

As a result, I am now having difficulty with:

Are you currently experiencing pain as a result of these symptoms? Yes No

Image

When did your symptom(s) begin? Date: ____________________

Please rate the Intensity and Frequency of your pain with "0" being no pain, "5" being moderate pain, and "10" being unbearable pain.

Your Pain Intensity Rating: ______________________________ Your Pain Frequency Rating: ______________________________

More specifically, rate your pain using the At its worst ____________________

same "0" to "10" scale. At its best ____________________

At present ____________________

Night (sleeping) ____________________

At what time of day are your symptoms the worst? ________________________________________________________________

At what time of day are your symptoms the best? _________________________________________________________________

What activities increase your pain? _______________________________________________________________________________

What activities decrease your pain? _______________________________________________________________________________

What other types of treatment have you had for this problem?

_____Massage _____Bodywork _____Physical Therapy _____Myofascial Release _____Chiropractic

_____Surgery _____Other Medical Treatment: (Please Describe) ________________________________________________

Check the box if you have had any of the following medical conditions?

__________ Diabetes __________ Varicose veins __________ Neurological problems

__________ Rheumatic fever __________ Circulatory problems __________ Stroke

__________ Heart Murmur __________ Lung disease __________ Broken bones (fracture)

__________ High blood pressure __________ Epilepsy/seizures __________ Kidney disease

__________ Heart disease/pacemaker __________ Malignancy __________ Liver disease

__________ Migraine headaches __________ Arthritis __________ Metal implants

__________ Osteoporosis __________ Pregnancy __________ Blackouts

__________ Weight change __________ Other: explain_______________________________________________

List past medical history and dates of occurrence. Include surgeries, accidents and other traumas.

_____________________________________________________________________________________________________________________

List ALL medications which you are currently taking, the condition for which you are using them, the dose, and their effectiveness. (Include Supplements, herbal and homeopathic remedies).

Medication for treatment of Dose/Amt. per day Effectiveness

_______________________________________________________________________________________________________________________

Do you have any skin or medication allergies? Yes __________ No __________

If so, which? ____________________________________________________________________________________________________________

Is there a chance you may be pregnant at this time? Yes __________ No __________

Do you engage in regular exercise? Yes __________ No __________

What type and how often? __________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

are you able to exercise now? Yes __________ No __________

Do you have discomfort, shortness of breath, or pain with exercise? Yes __________ No __________

Please describe ___________________________________________________________________________________

In general, your lifestyle is: 1 2 3 4 5

Active Average Inactive

If sleep is a problem, answer these questions:

Do you have trouble falling asleep? Yes __________ No __________

Is your sleep restful? Yes __________ No __________

Do you find it difficult to lie down? Yes __________ No __________

Do you find it difficult to change positions in bed? Yes __________ No __________

How many times do you wake in the night? _____________________________

How long before you fall back to sleep? ___________________________________________

List all the TASK/ACTIVITIES that you have difficulty performing and your tolerance (minutes/hours) for each task/activity. If you are no longer able to perform an activity, your tolerance would be "0".

Task/Activity Tolerance (minutes/hours)

1.__________________________________________ 1. _________________________________________

2. _________________________________________ 2. _________________________________________

3. _________________________________________ 3. _________________________________________

List the activities that you would like to be able to do as a result of therapy.

Activity Duration/How Often By When

1. _____________________________________________ _______________________________ ____________________________

2. _____________________________________________ _______________________________ ____________________________

3. _____________________________________________ _______________________________ ____________________________

Other Goals? ____________________________________________________________________________________________________________

I understand that Back In Motion Integrative Therapy, may use or disclose my personal health information for the purpose of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment.

Photographs taken during initial evaluation, progress evaluation and discharge summary will be used for postural comparison purposes and as educational tools. By signing below you consent to the use of these photographs in a professional manner.

I do hereby agree and give my consent for Back in Motion Integrative Therapy, to furnish care and treatment which is considered necessary and proper in the diagnosing or treatment of my physical conditions.

I understand that I retain the right to revoke this consent by notifying the practice in writing at any time.

I hereby certify that all the above information is true to the best of my knowledge.

Patient/Parent/Guardian Signature: ___________________________________________________ Date:________________________