Intake for Existing Patients

Patient Health History
Name *

First Name Last Name
Date of Initial Evaluation

Month Day Year
Date
Height *
Weight *
Do you have a prescription for Physical Therapy: *

Yes No
if yes, referring provider:
History of Present Conditions:
Current Complaints *
Body Part / Region: *
When did your symptoms start: *

Month Day Year
estimated date if you don't remember
If you are coming in due to an injury, how did you injure yourself?
Special orders from your physician:
Have you seen anyone else for this problem? Please list:
IE: Chiropractor, massage therapist, other Physical therapist
If you are coming in after a surgery, please explain:
Date of surgery:

Month Day Year
Date
Pain
Please describe your pain: (Burning/stabbing/ache) *
Where is the pain located? *
ie: Low back, Right hip, etc.
With activity

Morning Night With Activity At rest
How is your pain now? *
0= No Pain, 10= Very Severe Pain
How is your pain at it's best? *
0= No Pain, 10= Very Severe Pain
How is your pain at it's worst? *
0= No Pain, 10= Very Severe Pain
Are your symptoms getting:

Better Worse Staying the same
What makes your symptoms worse? *
What makes your symptoms better? *
What activities do you have difficulty doing? *
What previous activities do you want to resume?
Past Medical History
If you have had any of the following conditions, please check off all that apply

Cancer Lung disease Low Blood Sugar Unusual Joint Pain/Swelling Hepatitis Kidney Disease Cardiac/Heart problems Heartburn Osteoporosis/osteopenia History of fractures High/Low Blood Pressure Multiple Sclerosis or other neurodegenerative diseases Anemia Chest pain Thyroid condition Impaired vision Impaired Hearing Circulation problems Rheumatoid Arthritis Tuberculosis Epilepsy or seizure disorders Headaches or migraines Diabetes Asthma Depression Stroke Currently Pregnant Shortness of breath Allergies (Please list in "Other" section) Other
Have you recently noticed...?

Sudden unexplained weight loss/gain Nausea or Vomiting Weakness Fever Chills or sweats Numbness or tingling
Do you use...?

Cane Walker or Rollator Wheelchair Other
General health status:

Smoker Overweight/obese Alcohol Dependent Drug Dependent
Please list all previous surgeries and approximate dates:
ie: Left ACL reconstruction - 10/2012
Please list any diagnostic tests for this problem, dates of the test, and results:
ie: Xrays, 3/2021 , negative
Please list your current medications (OTC and supplements):
INFORMED CONSENT FOR PHYSICAL THERAPY SERVICES
Physical therapy is a patient care service that is provided in order to manage a wide variety of conditions. Services are provided to individuals of all ages regardless of gender, color, ethnicity, creed, national origin, or disability.

The purpose of physical therapy is to treat disease, injury and disability by examination, evaluation, diagnosis, prognosis and intervention by use of rehabilitative procedures, mobilization, massage, exercises, and physical agents to aid the patient in achieving their maximum potential within their capabilities and to accelerate convalescence and reduce the length of functional recovery. All procedures will be thoroughly explained to you before you are asked to perform them.

Response to physical therapy intervention varies from person to person; hence, it is not possible to accurately predict your response to a specific modality, procedure, or exercise protocol. Dynamic Edge Physiotherapy does not guarantee what your reaction will be to a specific treatment, nor does it guarantee that the treatment will help resolve the condition that you are seeking treatment for. Furthermore, there is a possibility that the physical therapy treatment may result in aggravation of existing symptoms and may cause pain or injury.

It is your right to decline any part of your treatment at any time before or during treatment, should you feel any discomfort or pain or have other unresolved concerns. It is your right to ask your physical therapist about the treatment they have planned based on your individual history, physical diagnosis, symptoms, and examination results.

Consequently, it is your right to discuss the potential risks and benefits involved in your treatment.

I have read this consent form and understand the risks involved in physical therapy and agree to fully cooperate, participate in all physical therapy procedures, and comply with the established plan of care.

I authorize the release of my medical information to appropriate third parties.
Patient Name *
Signature *

Clear
Date

Month Day Year
Date
FUNCTIONAL DRY NEEDLING CONSENT AND REQUEST FOR PROCEDURE
Functional Dry Needling (FDN) involves inserting a tiny monofilament needle in a muscle or muscles in order to release shortened bands of muscles and decrease trigger point activity. This can help resolve pain and muscle tension, and will promote healing. This is not traditional Chinese Acupuncture, but is instead a medical treatment that relies on a medical diagnosis to be effective.

Your physical therapist trained by KinetaCore® has met requirements for competency in Functional Dry Needling and is considered a certified Functional Dry Needling Practitioner. All training was in accordance with requirements dictated by this facility and by the U.S. state of this practitioner's licensure.

FDN is a valuable and effective treatment for musculoskeletal pain. Like any treatment, there are possible complications. While complications are rare in occurrence, they are real and must be considered prior to giving consent for treatment.

Risks:

The most serious risk with FDN is accidental puncture of a lung (pneumothorax) If this were to occur, it may likely require a chest x-ray and no further treatment. The symptoms of shortness of breath may last for several days to weeks. A more severe puncture can require reinflation of the lung. This is a very rare complication, and in skilled hands it should not be a major concern. Other risks include: injury to a blood vessel causing a bruise, infection, and/or nerve injury. Bruising is a common occurrence and should not be a concern.

Patient's Consent:

I understand that no guarantee or assurance has been made as to the results of this procedure and that it may not cure my condition. My therapist has also discussed with me the probability of success of this procedure, as well as the probability of serious side effects. Multiple treatment sessions may be required/needed, thus this consent will cover this treatment as well as consecutive treatments by this facility.

I have read and fully understand this consent form and understand that I should not sign this form until all items, including my questions, have read been explained. With my signature, I hereby consent to the performance of this procedure. I also consent to any measures necessary to correct complications which may result.

Procedure:

I authorize Dynamic Edge Physiotherapy to perform Functional Dry Needling as part of my physical therapy treatment.
DO NOT SIGN UNLESS YOU HAVE READ & THOROUGHLY UNDERSTAND THIS INFORMATION.

You have the right to withdraw consent for this procedure at any time before it is performed.
Patient or Authorized Representative Signature

Clear
Date

Month Day Year
Date
Relationship to Patient (if other than patient)
Should be Empty:

Patient Health History

Pain

INFORMED CONSENT FOR PHYSICAL THERAPY SERVICES

FUNCTIONAL DRY NEEDLING CONSENT AND REQUEST FOR PROCEDURE