subjective medical history information - ptosi - physical therapy

1. Which of the following best describes how your injurt occurred? (if your injury is post-surgical please indicate as per original injury

2. Nature of primary complaint

Please indicate the date your symptoms began? (please indicate specific date) ___________________________Surgery date (if applicable) ___________________________

Print this form and mark with a pen using the key below indicate on

the body diagrams where your symptoms are located.

X = Pain O = Tingling // = Numbness

Check the boxes indicating your pain at its lowest and highest levels.

0 1 2 3 4 5 6 7 8 9 10

________________________Date:

________________________Patient Name:

________________________Date of Birth:

________________________Patient Account #:

________________________Insurance:

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lifting a fall an incident at work overuse (cumulative trama) during recreation/sports ________________________________________________________________________ MVA (car accident) State accident occurred _____________________________________________________ other _________________________________________________________________________________________

dental appointment degenerative process unknown

pain numbness/tingling sharp dull throbbing aching burning intermittent constant weakness other __________________________

History of current condition

Subjective Medical History Information

3. Was the onset on this episode gradual or sudden? (check one)

4. Since onset are your symptoms getting: (check one)

6. As the day progresses do your symptoms: (check one)

7. Does pain wake you at night?

5. What relieves (R) / aggravates (A) your symptoms

If this is a flare up: original date of onset ________________________

Number of prior episodes ________________________

Frequency ________________________

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gradual sudden flare up

better worse not changing

increase decrease stay the same

yes no

_____ sitting _____ heat_____ cold_____ stretching_____ wearing a splint/brace_____ coughing/sneezing_____ other _________________________________________________________

_____ rest _____ standing_____ walking_____ exercise

_____ massage _____ medication_____ nothing_____ lying down

if the pain wakes you up at night, is it present

while lying still when changing positions both


9. Do you have pain/stiffness getting out of bed in the morning?

8. In what position do you sleep? (check all that apply)

10. Since your symptoms began have you had (check all that apply):

11. Current limitations (check all that apply):

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yes no

sitting heat other _________________________________________________________

fever / chills / nausea / vomiting any numbness in gential/anal area numbness / tingling / burning dizziness / fainting weakness none other _________________________________________________________

none talking taking a deep breath up/down stairs sitting _______________________________________________________ reaching _______________________________________________________ standing _______________________________________________________ walking _______________________________________________________ self care/hygene _______________________________________________________ home management activities _______________________________________________________ repetitive activities _______________________________________________________ sports / recreation _______________________________________________________ other _________________________________________________________

rest standing

looking overhead swallowing chewing yawning

massage medication

going from sit to stand lying down bending squatting

unexplained weight change night sweats / pain problems with vision / hearing / speech any difficulty with bladder / bowel function headaches


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12. Treatments previously received for this condition? (check all that apply)

medication Chiropractic Physical therapy massage bracing/taping surgery (date) _________________________________________________________ other ____________________________________________________

biofeedback/TENS TENS unit injection/acupuncture casting/immobilization hospitalization

13. Please check/list any other health care providers you are currently seeing for this condition:

14. Please check if you have had any of the following?

How would you rate your overall health?

none dentist Chiropractor MD _________________________________________________________

none CT scan / MRI other _________________________________________________________

excellent good average fair poor

Podiatrist Physical therapist

EMG x-rays

Dominant Hand? Right Left

General Health

_________Age: _________ Height:

Weight: _________


Do you drink caffeinated beverages?

What is your stress level?

Do you smoke?

Are you pregnant?

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yes no ________/day

low medium high

yes no ________/packs day

no yes date due: ___________

Apart from your daily activities do you exercise?

5+ days/week 3-4 days/week 1-2 days/week

occasionally zero

Medication

Please list any prescription and/or over the counter medication you are currently taking.(pain pills, injections, skin patches, aspirin, multi vitamins, etc.)

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________


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Have you ever had/benn diagnosed with any of the following conditions? (check all that apply)

Heart Problems HIV Stroke Kidney problems Thyroid Epilepsy / seizures / dizziness Diabetes Arthritis - OA/RA osteopenia/osteoporosis Head injury Circular/vascular problems Infections disease (i.e. hepatitis, tuberculosis, etc.) Cancer _________________________________________________________ Spine problems / surgery ____________________________________________________ List any other surgeries ____________________________________________________ other ____________________________________________________

Chemical dependency High blood pressure Depression Lung problems/asthma incontinence Blood disorder/anemia Multiple Sclerosis Allergies Fractures Stomach problems Parkinson’s

Past Current Medical History

Family History

Has anyone in your immediate family ever been diagnosed with any of the following?

Diabetes Stroke Heart disease Cancer _________________________________________________________ other _________________________________________________________

High blood pressure Arthritis OA/RA Psychological condition


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live alone live with family members/others/caregiver home / apartment / retirement complex driving other ___________________________________________________________

Independent in all activities (work, home, recreation, community)

stairs (railing) stairs (no railing) no stairs elevator other ___________________________________________________________

Independent (bathing, toileting, dressing, etc.) Difficulty performing self care activities Need assistance with self care activities Difficulty performing household chores

Limited in _____________________________________________________________________________________

Living Situation

Previous Functional Level

Environment

Self Care

Social / Recreational / Leisure

What are your goals for therapy?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


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Occupation

Physical activities at work

Current working status

full time part-time self other ____________________________________________________

sitting phone use heavy equipment operation standing

full duty restricted duty work days missed ______________

If not performing your normal activities at work, do you plan to return to your previous activity level?

Are you seeking disability or are you consulting an attorney for this condition?

Patient / guardian signature: _______________________________________________________________________

Reviewed by therapist: ____________________________________________________________________________

M.D. follow up date: _________________

Date: _________________

Work History

retired student unemployed

repetitive lifting computer use driving heavy lifting

yes no

yes no

Please fill out, print, and bring this form with you to your first appointment. Please arrive to your first appointment 15 minutes early for check in and insurance verification.


subjective medical history information - ptosi - physical therapy

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