NATURAL PERFORMANCE REHAB

522 ½ S TEJON ST

COLORADO SPRINGS, CO 80903

If you are seeing Dr. Miller, email this back to:

If you are seeing Dr. Wood, email this back to:

Physical Therapy Medical Screening Questionnaire

Name: Click here to enter text. Address:Click here to enter text. Email:Click here to enter text.

Date of Birth:Click here to enter text. Age:Click here to enter text.

Smoke/Dip: no Occupation:

Hobbies/Sports:

My goal for therapy:Click here to enter text.

Medications: deniesClick here to enter text.

Allergies:NKDA

CURRENT SYMPTOMS:

Where are you currently having issues?Bilateral anterior knee pain

What date (roughly) did you present issue start?

Did your issue start:☐Gradually?☐Suddenly?☐By Injury? Explain: many falls last year with painful knees with dull throb behind knee caps.

Have you ever had this problem before: ☐Yes ☐No If yes, when:Click here to enter text.

What aggravates your pain?

What eases your pain?

Past injuries/surgeries:

Past treatment:

In the past 6 months have you had or do you experience: CHECK ALL THAT APPLY

☐Fatigue / ☐Fever/chills/sweats / ☐Changes in bowel or bladder function
☐Difficulty swallowing / ☐Nausea/vomiting / ☐Weight loss/gain
☐Constipation/Diarrhea / ☐Heartburn/indigestion / ☐ Urinary tract infection
☐Change in balance / ☐Falls/balance issues / ☐Cough
☐Fainting / ☐Dizziness/lightheadedness / ☐Upper respiratory infection
☐ Shortness of breath / ☐Numbness or tingling / ☐Muscle weakness
☐Change in appetite / ☐Headaches / ☐Changes in mental status
☐Increased pain at night
Pain Scale: Where would you rate your pain right now? Fill in the number below. / 0
No Pain / 1/10 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
Worst Pain

Main complaint:1/10 currently and not much more just more noticeable

Other complaintsClick here to enter text.

Please move the corresponding box over the area of main painusing the diagram and the markings (also draw other pain areas that you may have at this time)

Ache Burning Numbness Pins and Needles Throbbing Other/General Pain

For Natural Performance Rehab staff beyond this point

SUBJECTIVE:

Main complaint:

When did it start?:

Other complaints:

Progression:

Aggravates:

Eases:

Special questions:

24 Hour Behavior:

Past medical history:

Past surgical history:

Past treatments and response:

Imaging:

Other tests:

Medications:

Allergies:

Patient goals:

OBJECTIVE:

Appearance:

Motion:

Strength:

Special Tests:

Gait/running:

Palpation:

Functional Testing:Click here to enter text.

Treatment:Click here to enter text.

CPT Codes:

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Assessment: Click here to enter text.

Diagnosis code: Click here to enter text.

Goals:Click here to enter text.

Plan:Click here to enter text.