/ SpecialtyPhysical Therapy

To ensure that you receive a complete and thorough evaluation, please answer the following questions on this form. If you are unsure how to answer any questions, please circle them. A therapist will review this questionnaire with you as part of your first visit. Thank you!

Name______Date of Birth______Primary reason for physical therapy______

Date of onset of symptoms ______Symptoms getting better worse staying the same

Medical History: Please check if you have ever had:

Arthritis

Broken bones/fractures

Osteoporosis

Blood disorders

Circulation/vascular problems

Heart problems

High blood pressure

Lung problems

Stroke

Diabetes

Low blood sugar/hypoglycemia

Head injury

Multiple Sclerosis

Back Pain/back surgery

Hip pain/hip surgery

Parkinson’s disease

Seizures/epilepsy

Allergies

Thyroid problems

Cancer: type______

Infectious disease/hepatitis/tuberculosis

Kidney problems

Repeated infections

Urinary Tract Infections

Bacterial/Non-bacterial Prostatitis

Benign Prostatic Hypertrophy (BPH)

Hemorrhoids

Hernia

Ulcers/stomach problems

Skin diseases

Depression

Blood clots

Other______

Surgeries/Hospitalizations: Please list any surgeries or other conditions for which you have been hospitalized, including the approximate date and reason for surgery or hospitalization:

DateSurgery/hospitalization DateSurgery/hospitalization

______

______

______

______

______

______

Family History: Please check if anyone in your immediate family (brothers, sisters, parents) has ever been treated for the following:

Diabetes

Heart disease

High blood pressure

Depression

Stroke

Kidney disease

 Cancer: Type______

Alcoholism (chemicaldependency)

Inflammatory Arthritis (Rheumatoid, Ankylosing)

Medications: Which of the following medications have you taken in the last week?

Physician Prescribed Not Prescribed by Physician

Aspirin

Tylenol

Anti-inflammatories(Advil/Motrin/Ibuprofen,etc)

Vitamins/mineral supplements

Herbals/Remedies

Others NOT prescribed by a physician______

Please list any other physician-prescribed medication you are currently taking (INCLUDING pills, injections,and/or skin patches):

1. ______

2.______

3.______

4. ______

5. ______

6.______

Is this a work-related or auto injury? ____ If yes, date of injury______

Have you seen a physical therapist this year? ____ If yes, how many visits have you had this year_____

Are you seeing a chiropractor? ____ If yes, how many visits have you had this year_____

May we obtain x-ray/MRI/CT scans/reports re: this condition? _____

How did you hear about Specialty Physical Therapy?______

Symptoms: Please check if you have experienced any of the following in the past 6 months:

_____Urinary Leakage: Date of onset______

  • Surgeries/interventions: (Please indicate date) none ______Robotic prostatectomy ______Radical prostatectomy ______Radiation therapy ______TURP ______other (please describe)______
  • Complications after these procedures:______
  • Type of pad used: none undergarment Guards or similar toilet tissue/paper towel use clamp
  • Number used per day: ______undergarment _____Guards or similar Per night: _____Undergarment _____Guards or similar
  • Activity increasing leakage: vigorous light change in position(e.g. sit to stand) bending Cough, sneeze, laugh lifting exercise Hearing running water arriving home walking to the bathroom leakage at rest

unable to feel leakage when it occurs

  • Urgency: strong urge causes leakage able to control urgency not aware of urgency/bladder fullness
  • Pattern: leakage increases as day progresses worse in the morning little/none at night no pattern
  • Medications: Ditropan Vesicare Detrol Enablex Other (indicate medication)______
  • Urinary Frequency: ______times per day ______times per night

_____Urinary Retention/difficulty emptying bladder/incomplete emptying: Date of onset______

_____Fecal Leakage: Date of onset______

  • Type of pad used: none undergarment Guards or similar toilet tissue/paper towel
  • Frequency of leakage: (indicate number) _____ times per day ______times per week ______per month
  • Number used per day: _____undergarment _____Guards or similar Per night: _____Undergarment _____Guards or similar
  • Activity increasing leakage: vigorous light change in position(e.g. sit to stand) bending lifting cough/sneeze/laugh exercise leakage happens at rest oozing afterBM unable to feel leakage occurring
  • Consistency of stool: hard soft oozing/staining
  • Medications taken for this:______

_____Constipation: Date of onset______

  • Frequency of bowel movement (indicate number) _____per day _____per week _____per month
  • Pain with bowel movement yes no
  • Consistency of stool: hard soft
  • Medications/supplements: Miralax/Dulcolax Metamucil Citrucel Senna stool softener/Colace Other(indicate)______

_____ Pelvic Pain: Date of onset______

  • Urinary Frequency: ______times per day ______times per night
  • Location abdomen scrotum penis anus/rectum bladder low back hips thighs
  • Frequency constant ______times per day ______times per week
  • Quality of pain sharp dull pulsing/throbbing ache pressure
  • Increased by: exercise light activity vigorous activity erection ejaculation sitting standing/walking bowel movement urination stress
  • Decreased by: nothing rest/lying down heat ice stretching/exercise urination BM medication(indicate which medication) ______
  • Intensity : Please indicate pain level from 0 (no pain) to 10 (worst possible pain)

At its worst: 0______5______10

At its best: 0______5______10

General level: 0______5______10

_____Erectile Dysfunction: Date of onset______

  • Difficulty achieving an erection maintaining an erection with ejaculation
  • Medication taken for this: Cialis Viagra Levitra Other ______
  • Use of pump yes no

Diet:

  • Daily fluid intake: ______8 oz glasses per day
  • Number of these which contain caffeine______
  • Number of these which contain carbonation/fizz_____
  • Number of these containing artificial sweeteners_____
  • Number of these containing alcohol_____
  • Do you smoke: No Yes _____Packs per day for _____years Quit: date______
  • Daily Fiber intake:______grams of fiber
  • Which of the following seem to affect your symptoms: caffeine spicy foods carbonated beverages alcoholic beverages Dairy products Wheat products Other:______

Exercise:

  • How often do you exercise: Never 1-2 times per week 3-4 timesper week 5-6 times per week daily
  • Type of exercise:
  • Cardiovascular (specify frequency and for how long): ______running ______walking ______bicycling Other(specify)______
  • Strength Training (specify frequency): ______Circuit ______free weights ______abdominal crunches/sit-ups ______Yoga______Pilates______Other(specify)______
  • Stretching:how often______before exercise after exercise
  • Do any of your exercises affect your symptoms(specify type):
  • ______makes it better
  • ______makes it worse

I certify that the information above is correct to the best of my knowledge. I understand and agree that I am personally responsible for full payment of all physical therapy services rendered to me. I hereby transfer/assign payment of any physical therapy insurance benefits directly to Specialty Physical Therapy and authorize release of any information regarding my treatment that is required by my insurance carrier to obtain such payment.

Signature______Date______

(Patient/guardian)