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? ____________________________________ ____________________________________________________________________________________________ .