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Dreher Physical Therapy

Orthopedics, Geriatrics, Neurology and Rheumatology

www.timdreherpt.com

Full Name:

Reason for care:

When and How did the symptoms start?

Pain/Quality of symptoms (check all that apply):

Achy

Dull

Stiff

Constant

Shooting

Burning

Numb

Tingling

Other

Other:

What makes the symptoms worse:

What makes the symptoms better:

Does the problem radiate to other parts of your body?

Any functional problems experienced on a daily basis (dressing, chores)?

What were you able to do before this injury that you can’t do now?

Where, on your body, are the areas of pain?

Is this on the right or left side of your body?

What is your pain level from 0-10 (0=none, 10=severe)? Please put 0 if you are in no pain.

Pain Level at your Best

Pain Level at your Worst

Pain Level Usually

Prior treatment, injections?

Please list any falls, car accidents, fractures, sprains, strains:

Did you receive an Xray, MRI, etc?

What were the results of the test?

Please bring in the written report of the tests, not the CD. Some of our computers can’t read the CD.

Please list all exercises, recreational activities and hobbies:

GOALS:

What do you hope to achieve with care?

REVIEW OF SYSTEMS: please check all of conditions that you have had or are currently experiencing.

Musculoskeletal:

Joint Pain

Arthritis

Scoliosis

Osteoporosis

Cardiovascular:

High Blood Pressure

Low Bloog Pressure

Angina

Heart Attack

Stroke

Poor Circulation

Sensory:

Blurred Vision

Ringing/Buzzing in Ears

Hearing Loss

Loss of Touch

Neurological:

Headaches

Migraines

Anxiety

Depression

Sleep Problems

Respiratory:

Asthma

Pneumonia

Emphysema

Sleep Apnea

Allergies

Endocrine

Immunue Disorders

Diabetes

Fatigue

Surgeries:

Please list any medications you are currently taking (you can bring a list to your first appointment):

Vitamins and supplements:

Other:

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