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802.399.2244
| Waterbury
802.882.8538
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Patient Intake / Medical History Form
First Name
Last Name
Date
MM slash DD slash YYYY
Date of Birth
MM slash DD slash YYYY
Please click on each image below to indicate location(s) of
PAIN
.
TODAY
PRIOR TO TODAY
Please click on each image below to indicate where you feel
NUMBNESS
or
TINGLING
.
TODAY
PRIOR TO TODAY
Please Rate your current pain levels on a scale of 0-10. 0 is no pain while 10 is worst pain imaginable.
What activities, postures or positions INCREASE your pain?
What makes your pain LESS bad?
Since its initiation, have your symptoms:
Worsened
Improved
Remained About the Same
Any other changes in symptoms?
Have you experienced these symptoms previously?
No
Yes
Please Explain
What do you think originally caused your pain?
Is your injury a result of a motor vehicle accident?
Yes
No
Have you had any diagnostic tests done for your current injury? (e.g. MRI, X-ray, etc)
Yes
No
If yes, what test(s)?
Have you had surgery recommended to you?
Yes
No
Have you had any past surgeries?
Yes
No
If yes, please explain.
Are you taking any medications?
Yes
No
Are you pregnant?
Yes
No
If yes, how many weeks?
What is the name of your Primary Care Physician and their clinic?
When was your last physical exam with your Primary Care Physician?
MM slash DD slash YYYY
Are you currently under the care of a physician, chiropractor, or other health care provider other than your Primary Care Physician?
Yes
No
If yes, please list them.
What are your goals for physical therapy?
Is there anything else you would like for us to know?
What is the best method for us to communicate with you? (To remind you of upcoming appointments, schedule future appointments, send exercises, etc.)
Email
Phone
Other
Email
Phone
Please explain how you'd like us to contact you
How did you hear about us?
Doctor / Provider Referred You
Friend / Family Member Referred You
Online Search
Found on Social Media
NewsPaper Ad
Other Ad / Banner / Sign
Other
Other - Please Explain
Date
MM slash DD slash YYYY
Consent
Check here if you're signing for an underage patient
Date
MM slash DD slash YYYY
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