INTAKE FORM FOR ANKLE INJURY

Date:
Patient Demographics
Last Name: Personal Contact information
Given Name: M.I.: Email:
Date of Birth: / / (MMM/DD/YYYY) Cellphone number:
Sex (Check ✓): M F Others Landline Number:
Marital Status (Check ✓): Single Married Divorced Widowed
Occupation: Person to contact in case of an emergency
Nationality: Name:
Religion: Contact number:
Weight: Height: Relationship to person:
Referring Doctor:

Information regarding Telerehab

Have you used Telehealth/Telerehab services before? Yes No

Are you comfortable in using Telehealth/Telerehab services? Yes No
What devices do you have access to? (Check all that apply)
Desktop PC Laptop Tablet Smartphone Other please specify:
What camera do you have access to? (Check all that apply)
Built-in device camera Webcam Other please specify:
What audio devices do you have access to? (Check all that apply)
Wired earphones Wireless earphones Built-in device microphone External microphone
Other please specify:
How do you access the internet? (Check all that apply)
Mobile Data Wi-fi LAN Other please specify:
What online platform/s are you comfortable in using? (Check all that apply)
Facebook Messenger Google Meet Zoom Viber Other please specify:
Which of the following items are available in your home?
Yoga mat Ball (stress ball/basketball/yoga ball) Dumb bells Weights long stick
Resistance bands/Thera band Stairs Stool
Do you have access to enough space to perform exercises? Yes No
Do you have anyone available to assist you if needed? Yes No
Write down any concerns, questions, or any information that you would like to know regarding Telerehab:

Chief Complaint (Why did you consult for Physical therapy?):

Goals for Physical Therapy (What do you want to achieve through Physical therapy?):

When did your symptoms started to occur? (Please provide a date or the most accurate time frame):

Describe what you think is the cause of your symptoms (Please provide exact scenario):

How have your symptoms evolved since the onset? (Select all that apply)
__Intermittent __Severely progressive
__Constant __Improving gradually
__Mildly progressive __Improving quickly
__Moderately progressive __Improving and have completely resolved
What activity-related symptoms are you experiencing? (Select all that apply)
__Pain at rest __Stiffness
__Pain with normal daily activities __Weakness
__Mechanical sensations (e.g., catching, locking) __Fatigue
__Audible sounds (e.g., clicking, popping) __Hypersensitivity
__Ankle Instability __Deficient sensation
__Lack of trust or confidence with the ankle __Numbness (complete absence of sensation)
Which ankle is affected?
Right Left Both
Have you had any prior injuries, dislocations, or surgeries involving the ankle?
__Yes, please describe:
__No

How would you describe the pain? (Select all that apply)
__Sharp __Deep
__Stabbing __Aching
__Shooting __Throbbing
__Shock-like __Burning
__Dull Other please specify:

On the scale of 0-10, 0 is no pain and 10 is most severe pain, what is your level of pain?
(No pain) 0 1 2 3 4 5 6 7 8 9 10 (Severe pain)

What aggravates your symptoms? (Select all that apply) What improves your symptoms? (Select all that apply)
__Standing __Performing typical job-related __Rest __Corticosteroid injections
__Descending stairs tasks __NSAIDs __Chiropractic treatments
__Sitting __Pivoting or changing direction __Cold therapy __Exercise
__Carrying loads __Working around the home __Narcotics __Massage
__Squatting/kneeling __Jumping __Heat therapy __Stretching
__Cycling __Sleeping __OTC pain __None
__Walking __Ascending stairs medications __Other:
__Exercising __None __Physical therapy
__Running __Other:

Do you have any numbness or tingling in the same extremity? Yes No

Does the pain radiate? Yes No
If yes, where does the pain radiate?

Mark an “x” on the images where you

feel pain?
Use the following key to indicate the
different type of symptoms
o Stabbing pain: xxxxx
o Burning pain: ////////////
o Deep Ache: 00000
o Pins and Needles: zzzzzzzz

What imaging test was performed on your ankle? (Check all that What was the result of the imaging test that was performed? (If you had
apply) undergone an imaging test)
__X-rays __EMG
__MRI __None
__CT Scan Other:
__Bone Scan

Have you ever had undergone a previous treatment for your ankle? Describe the outcome of the treatment (If you had undergone a previous
(Check all that apply) treatment)
__None __Injection
__Orthotics __Physical Therapy
__Cast immobilization __Chiro therapy
__Bracing __Other:
 Personal, Social and Environmental History What are your hobbies and interests?

Home environment
Number of children:
Number of floors/levels in the house: How motivated are you in your treatment on a scale of (0 – 10) with
Number of stairs in the house: 0 being not motivated at all, and 10 being extremely motivated?
0 1 2 3 4 5 6 7 8 9 10
Lifestyle
Alcoholic drinker? Yes No Describe the things that motivates you?
If yes, how many bottles per week?
Smoker? Yes No
If yes, how many packs per day? What is your attitude or outlook towards your therapy session?
How many years have you been smoking? Positive/looking forward
Caffeine intake: Yes No Neutral
If yes, how many cups per day? Negative/not looking forward
At what time do you usually go to sleep?
How many hours do you usually sleep?
At what time do you usually wake up? Foot and Ankle Disability Index (FADI)
How would you describe your level of activity? Please answer every question with one response that mostly describe
__Active __Sedentary your condition within the past week by marking the appropriate
number in the box. If the activity in question is limited by something
Exercise other than your foot or ankle, mark N/A.
What exercises do you usually do? (Select all that apply) 0 Unable to do 3 Slight difficulty
Walking Weightlifting 1 Extreme difficulty 4 No difficulty
Jogging/Running Yoga 2 Moderate difficulty
Biking/Cycling Outdoor recreational activity
Ball Sports Other:
Standing
How many minutes do you exercise per day? minutes
How days do you exercise per week? day/s Walking on even ground
Walking on even ground without shoes
Nutrition Walking on uneven ground
How would you describe your diet? Stepping up and down curves
Sleeping
How many times do you usually eat per day?
Walking initially
How many glasses of water do you drink per day?
Do you take vitamins? Yes No Walking approximately 10 times
Home responsibilities
Work environment Personal Care
What is your occupation? Heavy work (push/pulling, climbing, carrying)
Do you travel to arrive at work? Yes No Walking up hills
How would you describe the distance of your work from your home?
Walking down hills
How many hours per day do you work? Going up stairs
How many days per week do you work? Going down stairs
Describe your working conditions: Squatting
Coming up to your toes
How would you rate your stress level at work (0, no stress – 10, Walking 5 minutes or less
highest stress):
Walking 15 minutes or greater
Mental Activities of Daily Living
0 – Not at all 2 – More than half the days Light to moderate work (standing, walking)
1 – Several days 3 – Nearly everyday Recreational activities
Over the last 2 weeks, how often have 0 1 2 3
you been bothered by the following Pain related to the foot and ankle:
problems? (Check ✓) 0 Unbearable 3 Mild Pain
1. Feeling nervous, anxious or on edge 1 Severe Pain 4 No Pain
2 Moderate pain
2. Not being able to stop or control
worrying
General level of pain
3. Little interest or pleasure in doing
things Pain during your normal activity
4. Feeling down, depressed, or Pain at rest
hopeless Pain first thing in the morning
 Past Medical History
Do you have any allergies? Yes No
If yes, what allergies do you have?
Do you have any history of falls? Yes, how many in total? No
Do you have any history of joint instability? Yes No
Please indicate your other medical condition/s: Please indicate Post-Surgical History and Hospitalization:
1. Date: 1. Date:
2. Date: 2. Date:
3. Date: 3. Date:
4. Date: 4. Date:
5. Date: 5. Date:

Family Medical History

Medical Condition/s (e.g., Hypertension, Diabetes, Cancer etc.) Living?
Father Yes No
Mother Yes No
Sibling Yes No
Other: Yes No

Medication History
Please list all your current medications (include pain killers, prescription medicine, vitamins etc.)
1. Name: Dosage: Frequency: __________
2. Name: Dosage: Frequency: __________
3. Name: Dosage: Frequency: __________
4. Name: Dosage: Frequency: __________
5. Name: Dosage: Frequency: __________
6. Name: Dosage: Frequency: __________

Review Of Systems: (Select all that you have experienced recently)

Constitutional: Genitourinary: Hematologic:
__Fever __Difficulty urinating __Sickle cell disease
__Chills __Dysuria (pain when urinating) __Bruising
__Night sweats __Flank pain __Easy Bleeding
Eyes: __Blood in urine Psychological/Mental:
__Vertigo Musculoskeletal: __Confusion
__Change in vision __Joint pain __Anxiety
__Eye pain __Back pain __Self-inflicted injury
__Double vison Difficulty walking __Tension/Anxiety
__Visual disturbance __Joint swelling __Depression/Suicide ideation
Cardiovascular: __Muscle pain __Sleep problems
__Chest pain __Neck pain __Change in mood/attitude towards family/friends
__Leg swelling Neurological: Integumentary/Skin:
__Leg Pain __Dizziness Changes in skin color
__Fever __Headaches Rashes/lesion
__Cold Hands/Feet __Numbness __Open wounds
Respiratory: __Tingling __Change in hair/nails
__Shortness of breath __Seizures
__Chest tightness __Limb/muscle weakness
__COPD __Trouble walking
Gastrointestinal:
__Abdominal Pain
__Blood in stool
__Constipation
__Diarrhea

Did you get a COVID-19 Vaccination?

__Yes Brand: _____________ Dosage: ____________ Date: _________ __ No

PLEASE READ AND SIGN

The above information is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for notifying the
physician and/or medical staff of any, and all updates to the information listed above.

Patient Name & Signature: ___________________________ Date: ______________________________