2. Timeliness: If you are more than 15 minutes late, we may ask you to reschedule your appointment.

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1 Welcome to our clinic! Our goal at University of Wisconsin Hospital & Clinics is to offer the best possible care to our patients. We want to work with you to make that happen. To best work as a health care team we need your cooperation on the following: 1. Attendance: We understand situations happen which make it impossible for you to keep a scheduled appointment. If this happens, please call us as soon as you know the appointment will be missed. The earlier you let us know, the more likely we can offer your scheduled appointment time to another patient. Please call us at so we can reschedule the appointment for a date and time that will work for you. Missing appointments decreases your success with therapy. If you miss three appointments, you may be discharged. 2. Timeliness: If you are more than 15 minutes late, we may ask you to reschedule your appointment. 3. Insurance: You will be responsible for visits and charges that your insurance company does not cover. Please contact the customer service department of your insurance company for accurate information regarding your physical therapy benefits. I have read the above policy. Signature Date We look forward to meeting you, UW Spine Physical Therapy Research Park 621 Science Drive Madison, WI (608)

2 To ensure you receive a complete and thorough evaluation, please provide us with the important background information on the following form. If you do not understand a question leave it blank and your therapist will assist you. NAME: OCCUPATION: LEISURE ACTIVITIES: Primary MD: Referring MD: Daytime Phone Number where you can be reached: Date of Birth: Can we leave a phone message regarding physical therapy at this number? YES ALLERGIES: List any medication(s) you are allergic to: Are you latex sensitive? Yes No List any other allergies we should know about Have you declared the Advanced Clinical Directive of Do Not Resuscitate? Yes No Please check ( ) any of the following whose care you re under: Medical doctor (MD) Psychiatrist/Psychologist Other Osteopath Physical Therapist Dentist Chiropractor Have you EVER been diagnosed as having any of the following conditions? On the diagram below, please indicate the location of your symptoms YES Cancer. If YES, describe what kind: YES Heart Problems YES High blood pressure YES Circulation problems YES Osteopenia/Osteoporosis (brittle bones) YES Asthma YES Emphysema/Bronchitis YES Chemical dependency (i.e., alcoholism) YES Thyroid problems YES Diabetes YES Multiple sclerosis YES Rheumatoid arthritis YES Other arthritic conditions YES Depression YES Hepatitis YES Tuberculosis YES Stroke YES Kidney disease YES Anemia YES Epilepsy YES Other During the past month have you been feeling down, depressed or hopeless? YES During the past month have you been bothered by having little interest or pleasure in doing things? YES Do you ever feel unsafe at home or has anyone hit you or tried to injure you in any way? YES FOR WOMEN: Are you currently pregnant or think you might be pregnant? YES Have you recently noted: What is your preferred learning style? (Circle all that apply) YES weight loss/gain seeing hearing YES nausea/vomiting YES dizziness/lightheadedness doing reading YES fatigue YES weakness YES fever/chills/sweats YES numbness or tingling OVER

3 Please list any surgeries or other conditions for which you have been hospitalized, including the approximate date and reason for the surgery or hospitalization: DATE REASON FOR SURGERY/HOSPITALIZATION DATE REASON FOR SURGERY/HOSPITALIZATION Please describe any significant injuries for which you have been treated (including fractures, dislocations, sprains) and the approximate date of injury: DATE INJURY DATE INJURY Has anyone in your immediate family (parents, brothers, sisters) ever been treated for any of the following? YES Diabetes YES Cancer YES Tuberculosis YES Arthritis YES Heart disease YES Anemia YES High blood pressure YES Headaches YES Stroke YES Epilepsy YES Kidney disease YES Mental illness YES Alcoholism (chemical dependency) Which of the following OVER-THE-COUNTER medications have you taken in the last week? YES Aspirin YES Tylenol YES Advil/Motrin/Ibuprofen YES Laxatives YES Decongestants YES Antihistamines YES Antacid YES Vitamins/mineral supplements YES Other Please list any PRESCRIPTION medication you are currently taking (INCLUDING pills, injections, and/or skin patches): How much caffeinated coffee or caffeine containing beverages do you drink per day? How many packs of cigarettes do you smoke a day? How many days per week do you drink alcohol? How much do you drink at an average sitting? How many days/ week do you exercise? Please list 1-2 goals you would like to accomplish while enrolled in PT: Patient signature Date OVER

4 PATIENT WORKSHEET NAME Time am/pm r Initial Visit Date r Discharge Visit PROBLEM AREA (Please check one): r Upper Extremity (A,D) r Lower Extremity (B,F) r Cervical/Thoracic (C,D) r Lumbar (D,F) r TMJ (C,E) FUNCTIONAL INDEX PART I: Answer all five sections in Part 1. Choose the one answer in each section that best describes your condition. Walking r Symptoms do not prevent me walking any distance. r Symptoms prevent me walking more than 1 mile. r Symptoms prevent me walking more than 1/2 mile. r Symptoms prevent me walking more than 1/4 mile. r I can only walk using a stick or crutches. r I am in bed most of the time and have to crawl to the toilet. Work (Applies to work in home and outside) r I can do as much work as I want to. r I can only do my usual work, but no more. r I can do most of my usual work, but no more. r I cannot do my usual work. r I can hardly do any work at all (only light duty). r I cannot do any work at all. Personal Care (Washing, Dressing, etc.) r I can manage all personal care without r I can manage all personal care with some r Personal care requires slow, concise movements due to increased r I need help to manage some personal care. r I need help to manage all personal care. r I cannot manage any personal care. Sleeping r I have no trouble sleeping. r My sleep is mildly disturbed (less than 1 hr. sleepless). r My sleep is mildly disturbed (1 2 hrs. sleepless). r My sleep is moderately disturbed (2 3 hrs. sleepless). r My sleep is greatly disturbed (3 5 hrs. sleepless). r My sleep is completely disturbed (5 7 hrs. sleepless). Recreation/Sports (Indicate Sport if Appropriate ) r I am able to engage in all my recreational/sports activities without r I am able to engage in all my recreational/sports activities with some r I am able to engage in most, but not all of my usual recreational/ sports activities because of r I am able to engage in a few of my usual recreational/sports activities because of my r I can hardly do any recreational/sports activities because of r I cannot do any recreational/sports activities at all. ACUITY (Answer on initial visit.) How many days ago did onset/injury occur? days PART II: Choose the one answer that best describes your condition in the sections designated by your therapist. A. UPPER EXTREMITY Carrying r I can carry heavy loads without r I can carry heavy loads with some r I cannot carry heavy loads overhead, but I can manage if they are positioned close to my trunk. r I cannot carry heavy loads, but I can manage light to medium loads if they are positioned close to my trunk. r I can carry very light weights with some r I cannot lift or carry anything at all. Dressing r I can put on a shirt or blouse without r I can put on a shirt or blouse with some r It is painful to put on a shirt or blouse and I am slow and careful. r I need some help but I manage most of my shirt or blouse dressing. r I need help in most aspects of putting on my shirt or blouse. r I cannot put on a shirt or blouse at all. Reaching r I can reach to a high shelf to place an empty cup without r I can reach to a high shelf to place an empty cup with some r I can reach to a high shelf to place an empty cup with a moderate increase in r I cannot reach to a high shelf to place an empty cup, but I can reach up to a lower shelf without r I cannot reach up to a lower shelf without increased symptoms, but I can reach counter height to place an empty cup. r I cannot reach my hand above waist level without increased B. LOWER EXTREMITY Stairs r I can walk stairs comfortably without a rail. r I can walk stairs comfortably, but with a crutch, cane, or rail. r I can walk more than 1 flight of stairs, but with increased r I can walk less than 1 flight of stairs. r I can manage only a single step or curb. r I am unable to manage even a step or curb. Uneven Ground r I can walk normally on uneven ground without loss of balance or using a cane or crutches. r I can walk on uneven ground, but with loss of balance or with the use of a cane or crutches. r I have to walk very carefully on uneven ground without using a cane or crutches. r I have to walk very carefully on uneven ground even when using a cane or crutches. r I have to walk very carefully on uneven ground and require physical assistance to manage it. r I am unable to walk on uneven ground. PATIENT WORKSHEET Therapeutic Associates, Inc. (Revised: 12/16/10) FORM C004

5 C. CERVICAL/TMJ Concentration r I can concentrate fully when I want to with no difficulty r I can concentrate fully when I want to with slight difficulty. r I have a fair degree of difficulty in concentrating when I want to. r I have a lot of difficulty in concentrating when I want to. r I have a great deal of difficulty in concentrating when I want to. r I cannot concentrate at all. Headaches r I have no headaches at all. r I have slight headaches which come less than 3 per week. r I have moderate headaches which come infrequently. r I have moderate headaches which come 4 or more per week. r I have severe headaches which come frequently. r I have headaches almost all of the time. Reading r I can read as much as I want without r I can read as much as I want with slight r I can read as much as I want with moderate r I cannot read as much as I want because of moderate r I can hardly read at all because of severe r I cannot read at all. D. LUMBAR*/CERVICAL/UPPER EXTREMITY Driving r I can drive my car or travel without any extra r I can drive my car or travel as long as I want with slight r I can drive my car or travel as long as I want with moderate r I cannot drive my car or travel as long as I want because of moderate r I can hardly drive at all or travel because of severe r I cannot drive my car or travel at all. Lifting r I can lift heavy weights without extra r I can lift heavy weights but it gives extra r My symptoms prevent me from lifting heavy weights but I manage if they are conveniently positioned. (e.g. on a table) r My symptoms prevent me from lifting heavy weights but I manage light to medium weights if they are conveniently positioned. r I can lift only very light weights. r I cannot lift or carry anything at all. E. TMJ Talking r I can talk without any r I can talk as long as I want with slight symptoms in my jaws. r I can talk as long as I want with moderate symptoms in my jaws. r I cannot talk as long as I want because of moderate symptoms in my jaws. r I can hardly talk at all because of severe symptoms in my jaws. r I cannot talk at all. Eating r I can eat whatever I want without r I can eat whatever I want but it gives extra r Symptoms prevent me from eating regular food, but I can manage if I avoid hard foods. r Symptoms prevent me from chewing anything other than soft foods. r I can chew soft foods occasionally, but primarily adhere to a liquid diet. r I cannot chew at all and maintain a liquid diet. F. LUMBAR*/LOWER EXTREMITY Standing r I can stand as long as I want without r I can stand as long as I want, but it gives me extra r Symptoms prevent me from standing for more than 1 hour. r Symptoms prevent me from standing for more than 30 minutes. r Symptoms prevent me from standing for more than 10 minutes. r Symptoms prevent me from standing at all. Squatting r I can squat fully without the use of my arms for support. r I can squat fully, but with symptoms or using my arms for support. r I can squat 3/4 of my normal depth, but less than fully. r I can squat 1/2 of my normal depth, but less than 3/4. r I can squat 1/4 of my normal depth, but less than 1/2. r I am unable to squat any distance due to Sitting r I can sit in any chair as long as I like. r I can only sit in my favorite chair as long as I like. r My symptoms prevent me sitting more than 1 hour. r My symptoms prevent me sitting more than 1/2 hour. r My symptoms prevent me sitting more than 10 minutes. r My symptoms prevent me from sitting at all. * Lumbar questions adapted from Oswestry. PAIN INDEX Please indicate the worst your pain has been in the last 24 hours on the scale below No Pain Worst Pain Imaginable p l e a s e d o n o t c o m p l e t e T H E F O L L O W I N G S E C T I O N S o n f i r s t v i s i t GLOBAL RATING OF CHANGE With respect to the reason you sought treatment, how would you describe yourself now compared to your first treatment at our clinic? (Circle one) Very Much Worse Unchanged Completely Recovered Work Status (check most appropriate) 1. No lost work time 2. Return to work without restriction Work days lost due to condition: days 3. Return to work with modification 4. Have not returned to work 5. Not employed outside the home I am aware that the information gathered on this form may be used anonymously for research or publication. Please initial:

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