Please fill out form as completely as possible. Leave any questions blank that are not applicable to your condition.
Please also ensure that you have filled out the New Client Information Form as well.
First Name Last Name
Address
City State Zip
Home Ph Cell Ph Work Ph
Email Address
Date of Birth Gender: Male Female
Social Security #
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AREAS OF CONCERN
List areas of concern in order of severity (Example: 1. Right Knee 2. Right Ankle 3. Low back)
Area #1 Area #2 Area #3
Complete the following for each of the areas of concern listed above:
AREA #1
List your symptoms:
Your current pain level on a scale of 1-5 (0= No pain / 5 = Excruciating): 0 1 2 3 4 5
Your function level PRIOR to your injury (0% = Could not move / 100% = Perfect Function) %
Your function level AFTER your injury %
Status: Staying the same Improving Getting worse
What eases your symptoms? (Example: Ice, rest, medication, etc)
Have you received any treatment for this problem? Yes No (If yes, please describe)
What were the effects of the treatment?
Do you have any past medical history that may be related to this problem? Please explain.
If you have a related history:
How long did you have the problem?
How well was the problem resolved? (100% = complete resolution)
AREA #2
AREA #3
EMPLOYMENT INFORMATION
Occupation
Number of days worked per week Number of hours per week per day
Work classification: Select Sedentary (Lift up to 10 lbs occasionally) Light (Lift up to 20 lbs. occasionally) Medium (Lift up to 50 lbs. occasionally) Heavy (Lift up to 100 lbs. occasionally) Very Heavy (Lift in excess of 100 lbs. occasinally)
REVIEW OF GENERAL HEALTH
Domestic classification: Select Sedentary (Lift up to 10 lbs occasionally) Light (Lift up to 20 lbs. occasionally) Medium (Lift up to 50 lbs. occasionally) Heavy (Lift up to 100 lbs. occasionally) Very Heavy (Lift in excess of 100 lbs. occasinally)
Rate your overall fitness level Excellent Good Fair Poor Rate your overall health Excellent Good Fair Poor
Do you exercise on a regular basis? Yes No If yes, what type of exercise do you participate in? Days per week: Duration:
Rate your eating habits/nutrition level Excellent Good Fair Poor Height ' " Weight lbs.
Rate your sleep Excellent Good Fair Poor Hours in bed per night Restful hours in bed
Do you smoke tobacco? Yes No If yes, how much?
Do you drink alcohol? Yes No If yes, how much?
Do you drink caffeine? Yes No Type? Select Coffee Soda Tea Other How much?
Do you use controlled substances? Yes No If yes, how often?
Do you have any problems in the following areas?
Cardiopulmonary disorder/disease High blood pressure
Disorder of digestive system urinary tract kidneys hernia
Reproductive system OB/GYN Diabetes
Are you currently pregnant? Yes No
If you checked one or more items, please describe:
List any allergies:
List ALL medications that you are currently taking:
List any past serious illness:
List all operations and year performed:
List family history of illness and relationship to you (Example: Mother - cancer):