Patient Medical History and Intake Form

Patient Medical History and Intake Form

Please complete this form to the best of your ability with the fullest level of detail possible so that we are best able to address your needs. If you have any questions about anything on this form please reach out to us at rberghorn@ascentphysicaltherapyny.com or call 516-387-0053
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Date of Birth*

MonthDayYear
Date
How did you hear about us?*

Referring PhysicianFriend/Family MemberSearch Engine (Google, Yahoo, Bing)Social Media (Facebook, Youtube, Intstagram)Event/WorkshopOther
Who is your referring Physician/Specialist (if any)?
When did your condition start?*

Very recently - a few days agoA few weeks agoA few months agoUp to and over a year agoUnsure - it has been that longLooking more for prevention - Nothing hurts
Please choose all that apply*

I have had a fever within the past three monthsI have had bowel and bladder issues within the past 3 monthsI have had falls, motor vehicle accidents, or ER visits within the past 3 monthsI have had a fracture within the past 3 monthsI have had a recent change in medication within the past 3 monthsI have not had ANY of these things happen within the past 3 months
What hurts or why are you filling out this form?*
How did this condition start?*
How much is the problem impacting your life?*

I can't do certain things I love to doI am avoiding activity and not pushing myself because I am unsure if it is safe toI am doing everything - it just hurts or it is annoyingIt is not impacting my life right now but I am afraid it will in the future
Why are you looking to take care of this issue right NOW? (please be as detailed as possible so we are best able to address your needs)*
What value would us helping you bring to your life?*

Some value - I do not feel my condition is not that badAmazing value - I am in pain and would like this to be goneExceptional value - I am avoiding doing the things I love and it really sucksPriceless - if what I have is gone despite everything I have tried - it would be AMAZING!!Other
What goals/expectation do you have for your current condition? What would you like to get back to doing? (please be as detailed as possible)*
Overall what would you say your quality of health is at this moment?*

PoorFairGoodVery goodExcellent

What has your pain level been over the past 24 hours?*

	1	2	3	4	5	6	7	8	9	10

1 is No pain, 10 is TAKE ME TO THE HOSPITAL NOW!!!

What has your pain level been over the past week?*

	1	2	3	4	5	6	7	8	9	10

1 is No pain, 10 is TAKE ME TO THE HOSPITAL NOW!!!

How often do you experience your symptoms?*

Constantly (75-100%)Frequently (51-74%)Occasionally (26-50%)Intermittently (0-25%)No pain - Just want prevention
Have you had any of the following services prior to filling out this form?*

General PractitionerChiropractorEMG/NCVMassage TherapyNeurologistOrthopedistPodiatristX-rays/CT Scan/MRIOccupational TherapyPhysical TherapyEmergency RoomOther
Do you now or have you ever had any of the following?*

AsthmaBronchitis/EmphysemaHeart AttackChest pain/Angina/CADOther heart troubleGoutHigh Blood PressureShortness of BreathDiabetesThyroid/GoiterCancer/chemotherapy/radiatiomWeakness (unexplained)Dizziness/FaintingInfectious DiseasesUnintended weight lossOsteoporosisJoint replacementHeadachesEmotional problemsNumbness/tinglingVision/Hearing DifficultiesDo you have a pacemaker?Epilepsy/seizuresAllergiesAnemiaArthritisPins/Metal ImplantsSleeping problemsDepressionBlood clot/emboliPregnantStroke/TIAConcussion historyI HAVE NONE OF THESE
Please explain any of the above "Yes" answers or describe any medical issues in detail below
Please verify that you are human*
Signature*

Clear
(MINORS ONLY) Checking this box below is a certification that the patient in question is a minor and I am responsible for their care. I hereby agree to informed consent to video/photograph this minor under my care.

I AGREE
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