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Specialty Physical 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 Head injury Repeated infections Broken bones/fractures Multiple Sclerosis Urinary Tract Infections Osteoporosis Back Pain/back surgery Bacterial/Non-bacterial Prostatitis Blood disorders Hip pain/hip surgery Benign Prostatic Hypertrophy (BPH) Circulation/vascular problems Parkinson’s disease Hemorrhoids Heart problems Seizures/epilepsy Hernia High blood pressure Allergies Ulcers/stomach problems Lung problems Thyroid problems Skin diseases Stroke Cancer: type_________________ Depression Diabetes Infectious disease/hepatitis/tuberculosis Blood clots Low blood sugar/hypoglycemia Kidney problems 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: Date Surgery/hospitalization _______ _________________________________________ _______ _________________________________________ _______ _________________________________________ Date Surgery/hospitalization _______ _________________________________________ _______ _________________________________________ _______ _________________________________________ Family History: Please check if anyone in your immediate family (brothers, sisters, parents) has ever been treated for the following: Diabetes Depression Cancer: Type________________ Heart disease Stroke Alcoholism (chemical dependency) High blood pressure Kidney disease 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. _________________________________ 3.______________________________ 5. _____________________________ 2._________________________________ 4. ______________________________ 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 after BM 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 Medication taken for this: Cialis Use of pump yes no maintaining an erection Viagra Levitra with ejaculation Other __________________________________ Diet: Daily fluid intake: ______8 oz glasses per day o Number of these which contain caffeine______ o Number of these which contain carbonation/fizz_____ o Number of these containing artificial sweeteners_____ o 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 beverages Dairy products Wheat products Other:________________________________ alcoholic Exercise: How often do you exercise: Never 1-2 times per week 3-4 times per week 5-6 times per week daily Type of exercise: o Cardiovascular (specify frequency and for how long): _______________running ________________walking _________________bicycling Other(specify)__________________________________________________ o Strength Training (specify frequency): _______Circuit _______free weights _______abdominal crunches/sit-ups ________Yoga________Pilates________Other(specify)___________________________________________________ o Stretching: how often______________ before exercise after exercise Do any of your exercises affect your symptoms(specify type): o _____________________________________________________makes it better o _____________________________________________________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)
