Kate Schwartz Physical Therapy, LLC Patient Record Form and Agreement

Kate Schwartz Physical Therapy, LLC Patient Record Form and Agreement

Name:______Date of Birth:______Today’s Date:______

Height:______Weight:______Age:______R /L Handed?______

Current Medications, Vitamins/Supplements, with dosages:______

______

How and When did your present pain or injury begin?______

______

Have you ever had anything like this before? Yes / No. Explain:____________

Where is your pain/symptoms:______

Describe your current symptoms:______

How does it interfere with your everyday life:______

What increases your pain:______

What decreases your pain:______

Are your symptoms improving or worsening?______Are they intermittent or constant?______

What activities impact your symptoms?______

Rate today’s pain from Best (0) to worst (10) . Best:______Worst: ______

Is your pain worse at certain times of the day? If so when:______

Are there any restrictions set by your doctor? (Explain)______

What is your occupation:______

Are you currently working? Full time___ , Part time___, Unemployed___, Disability ___, Retired___,

Modified duty___. Out of work Date:______Days missed because of injury?_____ How does your problem

Interfere with work:______

List the maximum amount of time you can tolerate the following activities before you need to change position:

Sitting:______Walking:______Driving:______As a passenger:______

List any surgeries and dates:______

Have you previously had PT? If so, when______

Chiropractic?______Occupational Therapy?______Speech?______When?______

Any X-rays, MRI’s, CT Scan, EMG, etc? (Dates/results)______

PLEASE INDICATE ON THE DRAWING BELOW THE LOCATION OF YOUR SYMPTOMS

P – Pain N – Numbness T- Tingling B – Burning A - Achiness

Please check as many of the following health problems that you now have or have had:

Anemia or Blood Disease___Stomach/Intestinal Trouble ___Smoker (Y/N) ______

Heart Trouble/Murmur___ Liver/Gallbladder Disease ___How much day ______

High Blood Pressure___Hernia ___How long (yrs) ______

Chest Pain/Angina___Diabetes/Thyroid Disease ___

Shortness of Breath___Sugar/Protein in Urine ___

Lung Disease___Kidney/Bladder Trouble ___Do you drink Alcohol? __

Allergy/Hay Fever/Asthma___Headaches/Migraine ___Beer/Wine? ______

Eye Trouble___Dizziness/Fainting ___How much day/wk? ____

Deafness/Ear Trouble___Nervousness/Mental Illness ___

Major Illness___Paralysis/Nerve Disease ___Do you exercise regularly

Varicose Veins/Leg Sores___Broken Bones ___(at least 3 times a week)

Cancer/Tumor/Cyst___Joint or Back Injury ___YES NO

Bone/Joint Disease___Arthritis/Bursitis/Ganglion ___Doing what? ______

Back/Disc problems___Recent Weight Loss/Gain ___

Amputation Foot/Leg/Arm___Loss of Sight ___Are you pregnant now? __

Multiple Sclerosis___Cerebral Palsy ___Ages of children ______

Head Injury___Parkinson’s Disease ___(if any)

Seizures/Epilepsy___Stroke ___

Chronic Osteomylitis___Tuberculosis ___

Phlebitis___Hardening of Blood Vessels ___

Pacemaker___Osteoporosis ___

Fibromyalgia___Anxiety/Depression ___

Describe your major medical problems: ______