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Home > Intake Form Annual PT Physical for Adults

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Intake Form Annual PT Physical for Adults

Please complete the Medical History Form below.

Step 1 of 4

25%

Today's Date(Required)

MM slash DD slash YYYY

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

How did hear about PT Physical??

Occupation/employment status:(Required)

Retired

Full-time Company

Part-time Company

Unemployed

Primary Healthcare Provider(Required)

Other relevant health care provider(s):

Are you currently seeing a physical therapist?(Required)

Yes

No

Have you seen a physical therapist in the last year?(Required)

Yes

No

Emergency contact name(Required)

Emergency Contact Phone Number(Required)

Patient and Client Health and Wellness Goals

Relevant Medical History

Current Medications & Supplements(Required)

Have you been advised by a medical provider not to exercise?(Required)

Yes

No

What is your usual BP

Height(Required)

Weight(Required)

Do you have any of the following medical conditions?

Check all that apply

High blood pressure (BP)/hypertension

Heart attack

Heart surgery, cardiac catheterization, or coronary angioplasty

Pacemaker, implantable cardiac defibrillator, rhythm disturbance

Heart valve disease

Heart failure

Heart transplant

Congenital heart disease

Blood disorders (anemia)

Diabetes or high blood sugar

Hypoglycemia or low blood sugar

Kidney/urinary problems (urgency, leakage)

Arthritis (osteoarthritis, rheumatoid arthritis)

Osteoporosis or bone fractures

Musculoskeletal problems

Lung Problems (COPD, asthma, shortness of breath)

Depression

Neurologic diseases (Parkinson's disease, multiple sclerosis, stroke)

Head injury

Seizures, epilepsy

Cancer of any type

Thyroid problems

Stomach problems, ulcers

Bowel problems (constipation, gas/stool leakage)

Chronic pain

Altered sensation in hands, legs, feet

Wounds/ulcers/skin diseases

Infectious disease (e.g., tuberculosis, hepatitis)

Allergies (seasonal or other)

Balance or coordination problems

Difficulty swallowing

Major surgery

In the past year, have you experienced any of the following symptoms? If yes, please provide details.

Chest discomfort with exertion

Unexpected shortness of breath

Dizziness, fainting, or blackouts

Ankle swelling

Unpleasant awareness of forceful, rapid, or irregular heart rate

Burning or cramping sensations in the lower legs when walking a short distance

Details for any symptoms checked above

Is there any other information about your health or medical history you want to share?

Current Health Habits

Exercise

Do you exercise regularly?(Required)

Yes

No

Describe your average weekly exercise regimen:

On average, how many days a week do you perform moderate to vigorous intensity physical activity or exercise where your heart is beating faster and your breathing is harder than normal (a brisk walk)?(Required)

Please enter a number from 0 to 7.

On average, how many minutes do you engage in exercise at a moderate to vigorous level?(Required)

Please enter a number from 0 to 1440.

How many minutes per day or hours per week do you spend sitting?(Required)

Please enter a number from 0 to 1440.

Do you participate in muscle-strengthening activities?(Required)

Yes

No

Do you perform balance-training activities?(Required)

Yes

No

Tobacco/Nicotine use

Do you currently use any tobacco or nicotine products?(Required)

This includes cigarettes, cigars, chewing tobacco, vaping, etc.

Yes

No

If yes, what type of products do you use? How much do you use on a daily basis?

Cigarettes:

Cigar:

Chew:

Snuff:

Vapor:

Other

If you use tobacco or nicotine products, are you interested in quitting?

Yes

No

Alcohol use

Do you drink alcohol?(Required)

Yes

No

If yes, what do you drink

Check all that apply

Beer

Wine

Liquor

How many drinks per day?

1-3

4-6

More than 6

Diet

How would you rate your diet?(Required)

Good

Fair

Poor

How many servings of fruits and vegetables do you eat per day?(Required)

Please enter a number from 1 to 20.

How many cups or ounces of water do you drink per day?(Required)

Please enter a number from 1 to 100.

Sleep

Do you have difficulty falling asleep at night?(Required)

Yes

No

Do you wake up at night?(Required)

Yes

No

Do you snore or been told you snore?(Required)

Yes

No

On average, how many hours do you sleep per night?(Required)

Please enter a number from 1 to 20.

Hearing

Do you feel you have a hearing loss?(Required)

Yes

No

Functional activity review

Can you walk four blocks (1/2 mile) at a brisk pace?(Required)

Yes

No

How far can you walk before you get fatigued?(Required)

Can you climb one flight of stairs?(Required)

Yes

No

How many flights of stairs can you climb before you get fatigued?

Please enter a number from 1 to 100.

Can you carry five pounds of groceries up one flight of stairs without fatigue?(Required)

Yes

No

Can you get on and off the floor by yourself?(Required)

Yes

No

Can you stand up from a chair without using your arms?(Required)

Yes

No

While standing, can you turn in a circle (360 degrees) to the right and/or left?(Required)

Yes

No

Can you pick up a penny off the floor?(Required)

Yes

No

Can you participate in strenuous sports, such as swimming, singles tennis, football, basketball, or skiing?(Required)

Yes

No

Do you have difficulty with any other daily activities like dressing, bathing, toileting, or getting in or out of a car?(Required)

Yes

No

Falls History

Have you fallen in the past year?(Required)

Yes

No

If so, how many times?(Required)

Please enter a number from 1 to 365.

Do you feel unsteady when standing or walking?(Required)

Yes

No

Do you worry about falling?(Required)

Yes

No

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This website is an information and education resource for health professionals and individuals with injuries. It is not intended to be a service for patients and should not be regarded as a source of medical or diagnostic determination, or used as a substitute for professional medical instruction or advice. Not all conditions and treatment modalities are described on this website. Any liability (in negligence or otherwise) arising from any third party acting, or refraining from acting, on any information contained on this website is hereby excluded.

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