Patient Name
First
Last
Patient DOB
Diagnosis
Precautions
Have you ever been told you have any of the following conditions?
AnxietyHeart DiseaseCancerAngina/Chest PainDepressionStrokeDiabetesOsteoporosisHigh Blood PressureRheumatoid Arthritis
Do any of your immediate family members have these conditions?
YesNo
Do you have history of:
AllergiesHIV/AIDSHeadachesSeizuresBronchitisPacemaker PlacementKidney DiseaseCardiac SurgerySkin UlcersHepatitis A/B/CCirculation ProblemsTuberculosis
Please list all MEDICAL CONDITIONS or SURGERIES you have had that are not mentioned above.
In the past 3 months have you experienced or do you experience: PLEASE CHECK
A change in YOUR healthNausea/VomitingFever/Chills/Night SweatsUnexplained weight lossNumbness/tinglingChanges in AppetiteShortness of breathDifficulty SwallowingDizzinessLeg CrampsUrinary Tract InfectionsChanges in Bladder FunctionChanges in Bowel FunctionPregnantFeeling downUnder stress
How are you able to sleep at night?
FineModerate DifficultyOnly with Medication
Do you have a problem with:
HearingVisionSpeechCommunicationMemorySwallowing
Please list all medications you take and what they are for:
List allergies (i.e. allergies to medications, latex, adhesives, iodine, shellfish, etc.)
Do you or have you in the past smoked tobacco?
Packs/Day
Years Smoked
Date of Last Tobaccao Use
Do you drink alcoholic beverages?
What is your occupation?
What do you do for fun?
Do you live:
AloneAssisted LivingWith FamilyOther
Do you live in a:
1-story home2-story homeMobile HomeApartmentCondo
How many stairs do you have to enter your home?
No stairsRamp
Do you have railings?
RightLeftNone
How many stairs do you have inside?
How long have you had this problem?
Number of Years
Onset Date
What makes it better?
What makes it worse?
Are your symptoms worse in: AMAs day progressesPM
Are your symptoms now: BetterWorseSame as when they started?
Do you have trouble with: BendingSittingRisingStandingWalkingLying
What was your level of function before this problem?
Do you currently exercise? YesNo
How often do you exercise?
Date of last physical examination
When do you go back to see your doctor?
What are three (3) important activities you are unable to do, or are having difficulty with because of your injury or problem?
Pain/Symptom Scale
0 = No pain, 10 = worst pain (Emergency Room pain)
What is the worst your pain or symptom gets? (circle one)
012345678910
What is the best your pain or symptom gets? (circle one)
What is your current level of pain/symptom? (circle one)
Please use the diagram below to indicate where you feel symptoms right now.
Front Areas 1 - Face2 - Neck3 - Thyroid4 - Left Breast5 - Right Breast6 - Spleen7 - Liver8 - Stomach9 - Abdomen10 - Pelvis11 - Genitals12 - Thighs13 - Legs14 - Arms22 - Feet
Back Areas 14 - Arms15 - Back of Head16 - Nape17 - Upper Back18 - Middle Back19 - Lower Bac20 - Back of Thigh21 - Calve22 - Feet
Select they type of pain/discomfort you feel. If you have more than one area selected above please describe your pain/discomfort below.
Pins and NeedlesStabbingBurningDeep AcheNumbness
Describe Symptoms
I agree that the signature and initials will be the electronic representation of my signature and initials for all purposes when I use them on documents for Virtus Physical Therapy—just the same as pen-and-paper signature and initial.
Patient Email
Date
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