*2PHT* REHAB SERVICES PATIENT HISTORY QUESTIONNAIRE

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1 *2PHT* 2PHT Page 1 REHAB SERVICES PATIENT HISTORY QUESTIONNAIRE In order for us to fully address all aspects of your problem, the following information is needed. Please take time to complete this form. Feel free to ask for assistance or clarification. Thank You! NAME: Date: PERSONAL Do you speak and read English easily? Yes No If no, what language to you use daily? Are you 65 years of age or older? Yes* No Have you fallen in the last year? Yes* No (Therapist note: A YES* to either question requires a Fall Risk Assessment) HISTORY OF CURRENT COMPLAINT 1. What is the reason you are here for therapy? 2. How did this happen? (accident, etc.) 3. When did it start? Date: 4. Have you had this problem before? Yes No 5. Have you had therapy for this problem before? Yes No If yes, when? At what facility? How many visits? 6. Has your doctor run any of the following tests for your current problem? X-ray MRI CT EMG Vascular Studies Other: 7. Are you currently having pain or have you had pain in the recent past? Yes No (If you answered yes to #7, please answer questions 8-14) 8. On the picture, shade in the areas where you feel pain. 9. On the picture, put an X on the area that hurts the most. 10. Please rate your pain by circling the one number that best describes your pain right now. No Pain Moderate Pain Unbearable Pain Please check all the words that describe your pain: constant intermittent dull sharp shooting stabbing burning aching numb other CONTINUED MHP 0372 Rev. 9/09 PT

2 Patient History Questionnaire Page What % of your day does pain interfere with your daily activities? (i.e. 0% does not interfere at all, 100% interferes the entire day) 13. What makes your pain worse? (i.e. positions, heat, cold, medication) 14. What makes your pain better? (i.e. positions, heat, cold, medication) 15. Are you experiencing any of the following? Restlessness or twitching Less comfortable with, or avoid people Perspiration Less talkative than usual Flushing Increased crying Headache More pessimistic attitude of injury or future Stomach Ache Weight gain or loss of 10 lbs or more Apprehension Mood changes Trouble sleeping Bowel/Bladder Problems Low energy or chronic fatigue 16. What are your goals for therapy? EMPLOYMENT INFORMATION 1. Employer Self Employed Job title Shift If you are off work due to present injury/illness, what was the last day you worked? Is this injury job related? Yes No 2. Check those items that currently apply to you: Full-time Part-time Homemaker Work with restrictions Retired Not working due to this condition: Unemployed Student Medical Leave Disability 3. Expected return to work: CONTINUED ON NEXT PAGE

3 Patient History Questionnaire Page 3 MEDICAL HISTORY 1. Have you had, or do you now have, any of the following listed conditions? High Blood Pressure Heart Problems Pacemaker Panic Attacks Stroke Diabetes Gland Problems (thyroid) Arthritis Anxiety Cancer Lung Disease Circulation Problems Vision Problems Hearing Problems Stomach Problems (ulcers, etc.) Seizures Blood Disorder/Sickle Cell Depression Kidney or Bladder Control Problems Asthma Emphysema Current Smoker Breathing Problems Drink Alcohol: None Occasionally Often Other 2. Please list type and year of any surgeries you have had: 3. Please list any medication or herbal rememdies you are currently taking: 4. Are you allergic to: Cortisone/Dexamethasone Yes No Bee Stings Yes No Lidocaine/Novacaine Yes No Latex Yes No Pool Chemicals Yes No Please list any other allergies: 5. Is there any chance that you might be pregnant? Yes No 6. Are there any additional issues or concerns that you would like your therapist to be aware of? Next Doctor s Appointment: Please keep us updated on the date of your next doctor s appointment throughout your treatment program. Thank You! Signature Date

4 Page 4 OPTIMAL INSTRUMENT Difficulty Baseline Instructions: Please circle the level of you have for each activity today. without any with little with moderate with much Unable to do Not applicable 1. Lying flat 2. Rolling over 3. Moving lying to sitting 4. Sitting 5. Squatting 6. Bending/stooping 7. Balancing 8. Kneeling 9. Walking short distance 10. Walking long distance 11. Walking outdoors 12. Climbing stairs 13. Hopping 14. Jumping 15. Running 16. Pushing 17. Pulling 18. Reaching 19. Grasping 20. Lifting 21. Carrying 22. Thinking about all of the activities you would like to do, please mark an X at the point on the line that best describes your overall level of with these activities today. I have extreme doing any of the activities that I would like to do. I have no doing any of the activities that I would like to do. 23. From the above list, choose the 3 activities you would most like to be able to do without any (for example, if you would most like to be able to climb stairs, kneel, and hop without any, you would choose: ) , 2006 American Physical Therapy Association. All rights reserved. No part of this instrument may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise without prior permission of the American Physical Therapy Association. Contact or visit Adapted/revised in July 2005 and August 2006 with permission of APTA from Guccione AA, Mielenz TJ, De Vellis RF, et al. Development and testing of a self-report instrument to measure actions: Outpatient Physical Therapy Improvement in Movement Assessment Log (OPTIMAL). Phys Ther. 2005;85:

5 Instructions: Please circle the level of confidence you have for doing each activity today. 1. Lying flat 2. Rolling over 3. Moving lying to sitting 4. Sitting 5. Squatting 6. Bending/stooping 7. Balancing 8. Kneeling 9. Walking short distance 10. Walking long distance 11. Walking outdoors 12. Climbing stairs 13. Hopping 14. Jumping 15. Running 16. Pushing 17. Pulling 18. Reaching 19. Grasping 20. Lifting 21. Carrying Confidence Baseline Fully confident in my ability to perform Very confident Moderate Some confidence confidence Not confident in my ability to Not applicable perform Page Thinking about all the activities you like to do, please mark an X at the point on the line that best describes your overall level of confidence in performing these activities today: I have no confidence that I can do activities that I would want to do. I have complete confidence that I can do activities that I would want to do. 2005, 2006 American Physical Therapy Association. All rights reserved. No part of this instrument may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise without prior permission of the American Physical Therapy Association. Contact or visit Adapted/revised in July 2005 and August 2006 with permission of APTA from Guccione AA, Mielenz TJ, De Vellis RF, et al. Development and testing of a self-report instrument to measure actions: Outpatient Physical Therapy Improvement in Movement Assessment Log (OPTIMAL). Phys Ther. 2005;85:

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