Tell Us About Yourself:
In order to evaluate your condition fully, please be as accurate as possible. Thank you.
Name
First Name
Last Initial
Age
Gender
Male
Female
Occuptation
Are you working now?
Yes
No
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1. Where is your pain/problem?
2. What caused your pain/problem?
3. Approximately when did it start? Ex. 3 days ago, 6 months ago... etc.
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4. List ONE ACTIVITY that you are unable to do, that you absolutely want to be able to do again;
5. Have you ever had this same (or similar) pain/problem before? If yes, then when have you had it and please describe.
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6. In your understanding, what do you think will make it better?
7. How optimistic are you that you'll get better?
Extremely
Very
Fairly
Mildly
Not at all
Not sure
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8. What are some potential obstacles to you getting better?
9. Over the next 30 days, how many hours per week would you commit to getting better?
10. What are you expecting from Physical Therapy Studio?
11. On a scale of 1-10 (1-3 being mild, 4-6 being moderate, and 6-8 being severe), what is the pain level in the past couple of days?
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12. List any medications you are taking:
13. List all past surgeries with dates:
14. List all medical conditions you have (or were told you have):
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I understand that my candidacy for Physical Therapy Studio will be dependent upon my ability and willingness to improve. I have answered the questions above honestly and accurately to the best of my ability. The doctor/therapist will determine whether or not I am a viable candidate for Physical Therapy Studio and that my approval into their program is not guaranteed.
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Phone Number
-
Area Code
Phone Number
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
example@example.com
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