Wholistic Physical Therapy, P.C.
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1 Wholistic Physical Therapy, P.C. INITIAL EVALUATION SUBJECTIVE REPORT Date Name Address City State Zip Phone Occupation Age Height Weight Date of Birth SSN How did you hear about us? Referring Physician or Therapist Address Phone 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. 1. What is the primary complaint that brings you to WPT today? Secondary complaint? As a result, I am now having difficulty with:
2 Are you currently experiencing pain as a result of these symptoms? 2. When and how did your symptom(s) begin? Date: 3. Have you ever received the following treatment for this condition? Physical Therapy MFR Chiropractic Other Yes No How long? Helpful? 4. 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 5. List past medical history and dates of occurrence. Include surgeries, accidents and other traumas. 6. List ALL medications which you are currently taking, the problem 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
3 7. Do you have any skin or medication allergies? Yes No If so, which? 8. Is there a chance you may be pregnant at this time? Yes No 9. Do you smoke? Yes No cigar/cigarettes/pipe How much? When did you quit? 10. Please place an M in front of each item that you experience at least MONTHLY. Place a W in front of each item that you experience WEEKLY or more frequently. Headaches Feeling inadequate/unable to cope Chest pain, tightness Feeling guilty or like a failure Numbness, tingling in arms or legs Uncontrolled crying or sadness Sweaty palms Easily annoyed or irritated Excessive perspiration Free-floating anxiety about life Can t keep warm enough Blushing/flushed face Coughing Stuffy nose, congestion Nosebleeds Earache or ringing noise in ears Common colds Sore throat Asthma or shortness of breath Hay fever or allergies Sore, aching muscles Stiff or tender joints Back problems Trembling/twitching muscles Skin rashes, eruptions Grinding of teeth (TMJ) Dry mouth Mouth sores Difficulty falling asleep Difficulty sleeping through night Awaken too early in morning Excessive drowsiness during day Periods of extreme fatigue Eyestrain or discomfort Eyes irritated or inflamed Visual disturbances - blurry Stomach cramps Heartburn/indigestion Nausea or vomiting Frequent urination Incomplete urination Painful urination Urinary leakage Bowel leakage Diarrhea Constipation Bowel irregularity Frequent laxative use Uninterested in sex relations Unable to enjoy sexual activity Menstrual difficulties Pre-menstrual syndrome Breast tenderness Hot flashes
4 Feeling faint or dizzy Water retention Feeling tense or nervous Over-eating, bingeing Difficulties with family or friends Lack of appetite Worrisome thoughts Excessive alcohol abuse Recurring bad thoughts Other substance abuse Thoughts of suicide Other: Fearful of persons or places 11. Please rate the intensity of your pain with 0 being no pain, 5 being moderate pain, and 10 being unbearable pain. Your Pain Intensity Rating: 12. Please rate the frequency of your pain with 0 being never, 5 being intermittent, and 10 being constant. Your Pain Frequency Rating: 13. More specifically, rate your pain using the same 0 to 10 scale. At its worst At its best Most of the time Night (sleeping) 14. At what time of day are your symptoms the worst? At what time of day are your symptoms the best? 15. 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?
5 16. In general, your lifestyle is: Active Average Inactive 17. 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 To come to a sitting position from lying down? Yes / No Do you find it difficult to change positions in bed? How many times do you wake in the night? How long before you fall back to sleep? 18. What activities increase your pain? What activities decrease your pain? 19. Daily Activities Please estimate the amount of time, on average, you spend in each of the following activities per day. Sleeping Household Chores Working Sitting at desk Standing in place Driving Computer Work Talking on phone Playing (specify sports & hobbies) Other
6 How much total time do you tolerate being in a vertical position per day? (e.g. sitting, standing, walking, driving) hour(s) If you need to rest during the day, how often? And what is the total time? hour(s) How much total time do you tolerate being in a horizontal position per day? (e.g. reclining, laying down, sleeping) hour(s) I walk for I stand for I sit for up. minutes before needing to rest. minutes before needing to sit. minutes before needing to change positions/get Do you have trouble getting up from a chair? Yes / No Do you have trouble putting on your shoes and socks? / No Yes Do you have difficulty climbing stairs? Yes / No 20. If any daily activities are limited, answer this question. List all the Tasks/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 Functional Ability On the line scale below, place a check mark to indicate your level of daily functional ability.
7 Inactive Normal On a good day 0% 100% On a bad day 0% 100% 22. Patient Goals List the activities that you would like to be able to do as a result of therapy. Activity Duration/How Often By When Other Goals?
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Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340
Medical Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning our professional