Medical Screening Form

• 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?

  YesNo

• Packs/Day
  

  Years Smoked
  

  Date of Last Tobaccao Use
  
• Do you drink alcoholic beverages?

  YesNo

• 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?
  Do you have railings?

  RightLeftNone

• Current Condition

  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?
  
  Patient Name

  
  First

  
  Last
• 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)

  012345678910

  What is your current level of pain/symptom? (circle one)

  012345678910

• 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

• Signature

  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

  Patient Name

  
  First

  
  Last

  Date
  

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