Annual PT Exam Form - Abilene Physical Therapy & Sports Rehab

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Please complete the following form and submit BEFORE your visit. This will help the therapist, as he/she can review your answers before your visit. Please answer all questions to the best of your ability. Once you hit submit, a message will appear saying the form was sent successfully.

Annual Physical Therapy Exam
Pre-Exam Form
In order to evaluate your conditon fully, please be as accurate as possible. Thank you

* Indicates required field

Name *

First

Last

Date of Birth: MM/DD/YYYY *

Gender *

Male Female

Occupation *

Your Medical and Surgical History-Please Check all the apply *

Allergies Arthritis Asthma or other lung disease Blood disorder Bone fractures (list location below) Cancer (list type below) Circulation, vascular problems Depression Diabetes or high blood sugar Head Injury Heart problems (provide details below) High cholesterol Hypertension Thyroid problems Hypoglycemia or low blood sugar Infectious disease (eg, tuberculosis, hepatitis) Kidney problems Lung problems Major Surgery (list type and month/year in space below) Multiple sclerosis Muscular dystrophy Musculoskeletal problems Osteoporosis Parkinson disease Repeated infections Seizures, epilepsy Skin Diseases or open wounds Stroke Ulcers, stomach problems

Please give details for any checked items *

Within the Past Year - Check all that have occurred: *

Bowel problems Chest pain or chest discomfort with exertion Chronic cough Coordination problems Dizziness, fainting, or blackouts Difficulty sleeping Fever, chills, or sweats Heart palpitations Headaches Hernias Hoarseness Loss of appetite Loss of balance Nausea/vomiting Pain that wakes you at night Pain with sexual activity Pelvic or abdominal bloating or pain Restrictions from scars Shortness of breath Urinary problems (eg. difficulty emptying, leakage, etc) Weakness or swelling in arms or legs Weight loss or gain

Specifically for men *

History of prostate disease

Medical history -specifically for women *

History of endometriosis Menstrual cycle (including perimenopausal or menopausal) Pelvic disorders Pregnancies and pregnancy-related pain Vaginal and caesarian deliveries

Please list all prescription medications *

How many days a week are you physically active to a moderate or vigorous degree? *

How many minutes per day are you physically active? *

What activities/exercises are you involved with? *

List any activities you have difficulty participating in: *

List any areas of pain, lack of movement or weakness in your body: *

If you completed an Annual PT Exam last year, do you have any new health concerns in the past 12 months? Please list: *

Date of Scheduled Exam *

MM/DD/YYYY

Time of Scheduled Exam *

Phone Number *

Submit

The state of Kansas is a “Direct Access” state for Physical Therapy.
You can begin physical therapy with or without a referral from a physician.

Now with 2 Locations to Better Serve You!

103 Northwest 15th Street
Abilene, KS 67410
Phone: 785-263-3646
FAX: 785-263-3689

HOURS:
Monday - Friday
8:00 a.m - 5:00 p.m.

1030 North Marshall, Suite B
Chapman, KS 67431
Phone: 785-922-4016
FAX: 785-922-4018

HOURS:
Monday - 1 p.m. - 5 p.m.
Tuesday & Thursday 8 a.m. - 5 p.m.

Contact Us

Physical Therapy
Other Services
Meet the Staff
Testimonials
Patient Center
Contact
Insurance/Billing
Direct Access
Videos
FAQ
Career