Physical Therapy Assessment

Patient Name ______Sex M F Date ______First MI Last MM / DD / YYYY DOB______What are your goals? ______MM / DD / YYYY Medical History Have you been admitted to the Emergency Room in the past year? Yes No When? ______Have you been admitted to the Hospital in the past year?Yes No When? ______History or broken bones, fractures?Yes No When and Where?______Do you experience Headaches?Yes No How long do they last? ______How often do you have them? ______What makes them worse? ______What helps? ______Have you had any surgical procedure(s) performed? Yes No When? ______Describe the surgery: ______Have you experienced head trauma including concussion, traumatic brain injury, whiplash? Yes No When? ______Describe what happened: ______Have you ever been in a car accident? Yes No When? ______Did you play any sports in the past? Yes No What sport(s) and for how long? ______Do you experience muscle aches, pains, spasms, and/or muscle cramping? Yes No What makes it worse? ______What helps? ______Autoimmune Questions

Do you have a history of the following? (check all that apply)  Ankylosing Spondylosis  Chronic Pain Syndrome  Fibromyalgia  Frequent Illness  Immunocompromised  Lupus  Rheumatoid Arthritis

Patient Name ______Balance Questions Do you experience dizziness or imbalance? Yes No

Describe your symptoms (check all that apply) Vertigo/Spinning Disequilibrium Motion Sickness Lightheadedness Anxiety What makes your dizziness worse? ______Do you have a fear of falling? Yes No

If yes, what activities are you most fearful with? ______

Have you had a fall in the past year? Yes No How many? ______Do you have difficulty stepping up/down curbs or stairs? Yes No Any vision changes or issues? Yes No Describe: ______Do you have a difficult time walking in the dark? Yes No Do you have difficulty hearing? Yes No Do you have any ringing, humming, buzzing in your ears? Yes No

Cardiovascular Questions

Do you have a history of the following? (check all that apply)  A-Fib   Cardiovascular Disease  Congestive Heart Failure  Coronary Artery Disease  Heart Attack  Heart Murmur  High Blood Pressure  Pacemaker  Peripheral Vascular Disease  

Cognition Questions

Do you have a history of the following? (check all that apply)  Alzheimer’s   Anxiety  Dementia  Depression  Forgetful  Poor Concentration  Poor Memory

Neurological Questions

Do you have a history of the following? (check all that apply)  ALS   Multiple Sclerosis  Parkinson’s  Seizures  Spinal Cord Injury  Stroke

Orthopedic Questions Do you have Osteoporosis or Osteoarthritis?Yes No Do you experience Joint pain or Gout?Yes No Where? ______Do you experience numbness or tingling in the hands, fingers, feet, or toes? Yes No When? ______Do you currently wear shoe inserts? Yes No

Patient Name ______Pelvic/GU Questions Do you have a history of the following? (check all that apply)  Benign Prostate Hypertrophy  Diastasis Recti  Hernia  Pelvic Pain  Urge to Urinate  Urinary Incontinence

Have you ever been pregnant? Yes No How many times? ______

Have you had any surgeries or procedures around your abdomen (including c-section)? Yes No When? ______Pulmonary Questions

Do you have a history of the following? (check all that apply)  Allergies  Asthma  Chronic Bronchitis  COPD  Cystic Fibrosis  Emphysema  Pneumonia  Poor Endurance  Shortness of Breath   

Other Questions Do you use cold, heat or compression therapy at home? Yes No Do you a TENs unit? Yes No What do you currently do for exercise and activity? ______Do you have difficulty sleeping? Yes No How many hours of sleep do you get at night? ______What position do you sleep in? ______

Medications List all current medications, vitamins, and supplements you are taking: Medication, Vitamin, Supplement Dosage (mg) How Often? Route Taken

Do you take any Statin medications? Yes No

Is there anything else you would like our clinical team to know? ______