Dreher Physical Therapy

Orthopedics, Geriatrics, Neurology and Rheumatology

www.timdreherpt.com

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

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

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

GOALS:

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

Musculoskeletal:
Cardiovascular:
Sensory:
Neurological:
Respiratory:
Endocrine

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