Physical Therapy
ASTYM/IASTM
Back & Neck Pain
Balance Training
Dry Needling
Foot Pain
Functional Rehab
Joint Pain
LSVT BIG (Parkinson's)
Manual Therapy
Pediatric Therapy
Post Covid Recovery
Pre/Post Operative
Sports Rehabilitation
Women's Pelvic Floor
Workman's Comp
Other Services
Annual PT Exam
Discovery Visit
Parkinson's Support Group
Wellness
Meet the Staff
Testimonials
Patient Center
Contact
Insurance/Billing
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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
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First
Last
Date of Birth: MM/DD/YYYY
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Gender
*
Male
Female
Occupation
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Your Medical and Surgical History-Please Check all the apply
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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
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Within the Past Year - Check all that have occurred:
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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
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History of prostate disease
Medical history -specifically for women
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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
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How many days a week are you physically active to a moderate or vigorous degree?
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How many minutes per day are you physically active?
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What activities/exercises are you involved with?
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List any activities you have difficulty participating in:
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List any areas of pain, lack of movement or weakness in your body:
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If you completed an Annual PT Exam last year, do you have any new health concerns in the past 12 months? Please list:
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Date of Scheduled Exam
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MM/DD/YYYY
Time of Scheduled Exam
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Phone Number
*
Submit
Physical Therapy
ASTYM/IASTM
Back & Neck Pain
Balance Training
Dry Needling
Foot Pain
Functional Rehab
Joint Pain
LSVT BIG (Parkinson's)
Manual Therapy
Pediatric Therapy
Post Covid Recovery
Pre/Post Operative
Sports Rehabilitation
Women's Pelvic Floor
Workman's Comp
Other Services
Annual PT Exam
Discovery Visit
Parkinson's Support Group
Wellness
Meet the Staff
Testimonials
Patient Center
Contact
Insurance/Billing
Direct Access
Videos
FAQ
Career