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Intake Sheets |
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Do It Better Patient Intake PATIENT INFORMATION ~ please fill in all fields. Thank you! Patient Last Name: _____________________ First Name:__________________ MI:_____ Address:__________________________________________________ Town:________________Zip:__________ Social Security Number:______/______/_____ Name of Health Insurance co_______________________ Policy number__________________________ Group #_______________ Name and # of insured___________________________Date of Birth_________________________ Phone Number Home: ____________________ Cell Number: ____________________________ E-mail address: __________________________ MD: ____________________ EMPLOYER INFORMATION ~ Employer Name:___________________________________________________ Occupation: ______________________________________________________ Employer Address:_________________________________________________ Employer Phone Number: ______________________ I certify that the above information is true and correct to the best of my knowledge and I herby consent to the release of , and receipt of my confidential medical and patient information from and to Do It Better. I also understand that my participation in this program is essential. And that any cancellation of appointments without 24 hour notice will hold me responsible for a $25 fee payable to Do It Better. I also understand that if I utilize direct access(no physician prescription), my insurance may not cover the cost of this treatment (making me 100% liable) Signature: _______________________________________ Today’s Date: ___/___/___ If patient required assistance to complete – Sign name and relationship below (i.e. parent, spouse) Name:______________________Relationship:_______________ Date:___/____/___ Perform Better What would you like help in doing better? ____________________________________________________________________ How do you want to apply this to sport or life? ____________________________________________________________________ List any physical activities you can think of in your personal and professional life that require compensated movement, or little glitches in the manner you perform? ____________________________________________________________________ Please circle below, if you have experienced any of the following symptoms: Pain Loss of motion Loss of balance Lack of coordination Weakness Sleeplessness Swelling Numbness Dizziness Light headedness Fatigue Sweating Nausea Restless arm/leg Urination > 5x in 24 hrs If circled, when do you feel (have you felt) the symptoms: _______________________________________________________________________ Have any tests been performed? (If yes, what) _________________________________ _______________________________________________________________________ Please circle any activities you wish you could perform better. Lying Rolling Throwing Gripping Sitting Crawling Hitting Handling Standing Creeping Kicking Pinching Kneeling Walking Dribbling Fingering Squatting Stepping Catching Standing Climbing Pushing Jogging Pulling Coordinating Reaching Running Carrying Balancing Shifting Hopping Swinging Accelerating Turning Skipping Decelerating Lunging Jumping Pivoting
Mark Areas of Concern If you have pain, please circle a number related to its intensity
0--------1---------2---------3--------4--------5--------6--------7---------8--------9-------10 no pain minimal moderate severe very severe worst
If you have pain, please circle the percent of the day you experience it
0-25%------------26-50%-----------51-75%----------75-100%
General Health Please circle all conditions that have ever applied to you: Arthritis Heart Disease Stomach Disorder Cancer High Blood Pressure Anxiety Diabetes Lung Disease Depression Stroke Thyroid Problems Panic Attacks Pace Maker Other: ____________________________________________________ Please circle all conditions that currently apply to you: Hearing Problems Pregnant Visual Problems Bowel or Bladder Control Learning Problems Smoke List all old injuries (ie sprains, strains, twists, fractures, whiplash, and car accidents) _________________________________________________________________________________________ MOST IMPORTANT I want to be able to _____________________________________________________________ this is difficult now because_______________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
If I were to come back in 1 year, I want to say I am now able to: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ |
