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Patient Intake Patient Name: Birth Date: Gender: Appt Date: Rendering Provider: Your Current Problem Height: feet inches Hand dominance: Left Weight Right PAIN DIAGRAM: pounds Ambidextrous Your chief complaint: Mark all the areas on your body where you feel pain. Please print out the form and mark using the appropriate symbol. Numbness = oooo Pins and needles = //// Pain = xxxx How long does it last when it occurs: less than 5 minutes 5-15 minutes 15-30 minutes 30-60 minutes greater than 60 minutes On a scale of 1-10, how severe is it (choose one only): 1 2 3 4 5 6 How frequently does it occur: Intermittently Occasionally Does the pain travel: Yes 7 8 9 Persistently 10 Rarely No If yes, where? What is the date of the injury (mm/dd/yyyy): - - When did the symptoms start (mm/dd/yyyy): - - Associated symptoms and location: Swelling Redness Deformity v2 Mass (lump) Bruising Numbness/tingling Weakness Clicking/popping Please continue on other side Limp Skin changes Locking/giving way Buckling/giving way Other: ______________ Page 1 of 3 Have you had any treatment for this problem? (if yes, please explain) Medications (please list) Surgery (date, procedure) Physical therapy (number of visits, results) Tens/H Wave Unit (location, number, results) Acupuncture (number of visits, results) Chiropractic (number of visits, results) Injections (location, number, results) Bracing, splinting, casting (how long, results) Diagnostic: X-ray MRI CT Scan EMG (Nerve Test) Other Name of physician(s) seen, clinic or hospital where you were treated and when: Check the appropriate box if your problem is made worse by any of the following. Bending Lifting Pushing Standing Climbing stairs Descending stairs Movement Sitting Walking Other aggravating factors: Please describe any other injuries to the same or different body parts (sprains, strains, fractures) and give approximate dates: If this is a work related injury, please proceed to the following page. v2 Page 2 of 3 Employer at the time of injury: Claim Number: Job Title: Usual Job Duties Please mark the frequency of your job activities PRIOR to your current injury. Please check where applicable or if the question does not apply, please mark "none". Sitting Standing Walking Reaching Manipulating Keyboard Use Grasping Bending Squatting Kneeling Climbing Lifting Pushing Pulling occasional occasional occasional occasional occasional occasional occasional intermittent intermittent intermittent intermittent intermittent intermittent intermittent frequent frequent frequent frequent frequent frequent frequent Rarely Rarely Rarely Rarely Rarely Rarely Rarely None None None None None None None occasional occasional occasional occasional occasional occasional occasional intermittent intermittent intermittent intermittent intermittent intermittent intermittent frequent frequent frequent frequent frequent frequent frequent Rarely Rarely Rarely Rarely Rarely Rarely Rarely None None None None None None None Maximum weight required to lift: ____________ pounds Time off work due to the injury (dates or approximate periods): ___________________________________ Modified work (dates, restrictions): ___________________________________________________________ Current work status: full duty restricted duty off work disabled If you are working, is there anything that you cannot do currently that you were able to do prior to the injury? v2 Page 3 of 3
