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Name: _____________________________________ Age: _______ Sex: ________ Occupation: ____________

Height: _________ Weight: ________ Phone: ___________________ Email: ____________________________
Address: ___________________________________________________________________________________
Employer/Insurer: __________________________ Referred by: _____________________________________
Diagnosis on Referral: ____________________________________
Family History: ______________________________________________________________________________
Medical History: _____________________________________________________________________________
___________________________________________________________________________________________
Present Medical History: _____________________________________________________________________
___________________________________________________________________________________________

Date of Injury __________ Date of Surgery __________ Type of Surgery: ______________________________

Chief Complaint/Ailment/Injury: _______________________________________________________________
___________________________________________________________________________________________

Vital Signs:

BP: mmHg
HR: bpm
Temp:

Briefly describe how you were injured:

__________________________________________________________________________________________
__________________________________________________________________________________________

Have you received therapy for this condition? O Yes O No When? _________________
How many visits? _________________________
Has your condition been getting: O Worse O Same O Better
Are your Symptoms: O Constant or O Intermittent
Mark the number that best corresponds to your pain:

O 0 O 1 O 2 O 3 O 4 O 5 O 6 O 7 O 8 O 9 O 10 (Excruciating pain)
What decreases/makes your condition better? (Mark all that apply)
Bending Movement Rest Better in AM
Sitting Standing Heat Better as day progress
Rising Walking Ice Better in PM
Changing positions Lying Medication Others: _______________
What increases/makes your condition worse? (Mark all that apply)
Bending Movement Rest Worse in AM
Sitting Standing Stairs Worse in PM
Rising Walking Cough Deep breath
Prolonged positioning Lying Sneeze Others: _______________

What are your goals to be achieved by the end of therapy?

__________________________________________________________________________________________
__________________________________________________________________________________________

Medical Information (Mark all that apply)

Difficulty in swallowing Motion Sickness Stroke Cancer
Arthritis Fever/chills/sweats Osteoporosis
High blood pressure Anemia Others: _______________
Unexplained wt loss
Heart trouble Blood clot Bleeding problem
Pacemaker Shortness of Breath HIV/Hepatitis
Epilepsy/seizures History of smoking History of alcohol abuse
History of drug abuse Diabetes Depression/anxiety
Myofascial Pain Fibromyalgia Pregnancy

Previous Surgeries:
__________________________________________________________________________________________
Other:
__________________________________________________________________________________________

Medication:
__________________________________________________________________________________________

Allergies:
__________________________________________________________________________________________

Physiotherapist Name/Signature Date