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Download Patient Intake Part 1 - Fitzgerald Physical Therapy
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Patient Intake Form Patient Name:_________________________________________Date Completed:__________Age:____ MEDICAL HISTORY: Indicates Surgeries and date/year:_____________________ Right / Left Handed Male / Female Height:__________ Weight:_______ _____________________________________________________ Check which apply: What is the problem you are here for?: _______________________________________ Date of injury or when symptoms started?: _______________________________________ Date of Surgery (If applicable): _____________ Chest Pain [ ] Fatigue Shortness of breath [ ] Balance Problems Change in bathroom habits Significant Weight Loss [ ] Swelling Headaches [ ] Dizziness Fainting [ ] Sleeping Problems Other(specify):_________________________________ Check which apply to your injury: Work-related Motor vehicle accident Athletic / recreational injury Injury related to lifting or falling Recurrence of previous injury Cause unknown Other (specify):___________________________ Is this the first time you have had these symptoms? Yes/No If NO, then when? : _________________________________ WORK HISTORY: Are you employed? YES NO Are you presently working? YES NO If NO, then date of last work day? ________________________ Current Occupation? : __________________________________ Where are you employed? : ______________________________ What treatments have you tried? Medications - Physical Therapy – Massage -- Chiropractic – Surgery Other (specify):___________________________________ SOCIAL HISTORY: Please list ALL medications you are taking at this time: Do you smoke? YES NO _____________________________________________________ Marital Status? _____________________________________________________ _____________________________________________________ S Drink Alcohol? YES M W D Do you regularly exercise? Children? YES YES NO NO NO Does your current condition affect your daily routine? YES Are you a caretaker for anyone? YES NO PAST MEDICAL HISTORY: Do you live alone? YES NO Do you have pets? YES NO Check which apply High Blood Pressure [ ] Stroke Emphysema [ ] Diabetes Seizure Disorder [ ] Asthma Heart Disease [ ] Cancer Thyroid Disease [ ] Dementia GI Disorder [ ] HIV/AIDS COPD/Emphysema Other: _____________________________________ If FEMALE, Are you pregnant? YES Does your family have a history of cancer? NO YES NO Do you drive yourself? YES NO Have you had any changes in mood, motivation, or interest in daily activities? YES NO Do you have any known attention deficits? YES NO NO
