1524 Dekalb Pike Blue Bell, PA 19422  
610.275.0330  
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Please bring your insurance card with you to your first visit.

Patient Information
Date
Name
Email
Age
Occupation/ Leisure Activities  
When was the onset of your problem?
Where was the pain initially felt?       
Now, where is the pain?    Pain Rating (0-10)   
How severe is your pain? Pain Rating (0-10)
Type of pain
Dull Sharp Throbbing Constant  
Intermittent Sore Bruised Burning  
         
Are you currently seeing any of the following
Medical Doctor Yes No
Osteopath Yes No
Dentist Yes No
Psychiatrist/Psychologist Yes No
Chiropractor Yes No
If you have been seen by any of the above during the past three months, please describe for what reasons (illness, medical condition, physical exam, etc.)
   
Please list any surgeries/injuries or other conditions for which you have been hospitalized, including the approximate date and reason for the surgery or hospitalization:
Date:  Surgery:
Date:  Surgery:
Date:  Surgery:
Date:  Surgery:
Date:  Surgery:
Date:  Surgery:
   
Please list ALL over-the-counter and prescription medications that you are currently taking. Please also provide the dosage of each medication.
Medication:  Dosage:
Medication:  Dosage:
Medication:  Dosage:
Medication:  Dosage:
Medication:  Dosage:
Medication:  Dosage:

How much coffee or caffeine containing beverages do you drink a day?

How many packs of cigarettes do you smoke a day?
How many days a week do you drink alcohol?


Have you or any of your family ever been diagnosed as having any of the following

Cancer - Yes   No   What type?

CONDITION YES NO
Heart Problems
High Blood Pressure
Asthma
Emphysema
Rheumatoid Arthritis
Depression
Tuberculosis
Kidney Disease
Epilepsy
CONDITION YES NO
Chemical Dependency (e.g. alcoholism)
Thyroid Problems
Diabetes
Multiple Sclerosis
Other Arthritic Conditions
Hepatitis
Stroke
Anemia
Other

Have you had, or do you experience:

CARDIOVASCULAR SYSTEM YES NO
Elevated cholesterol
Sweating associated with pain
Palpitations
Swelling of extremities
History of smoking
Orthopnea (difficulty breathing)

 

GU SYSTEM YES NO
Dysuria (painful urination)
Hematuria (blood in urine)
Incontinence
Frequency of urination
Urinary urgency
Vaginal discharge
Dysmenorrhea (painful menstruation)
Post menopausal vaginal bleeding
Painful intercourse
Hx of STD
Infertility
Date of Last Period

 

NEUROLOGICAL SYSTEM YES NO
Ataxia (poor muscular coordination)
Memory lapses
Confusion
Head Trauma
Neurological disorder
Tremors
Slurred speech patterns
Hearing/Visual disturbances

 

 

GI SYSTEM YES NO
Difficulty swallowing
Heartburn
Jaundice (yellow appearance)
Specific food intolerance
Constipation
Diarrhea
Change in color of stool
Rectal bleeding
Gall bladder problems
Liver Problems

 

PULMONARY SYSTEM YES NO
Dyspnea (labored breathing)
Wheezing
Prolonged cough
Sputum production
Amount/Color

 

ENDOCRINE SYSTEM YES NO
Excessive thirst
Excessive Hunger
Polyuria (large volume of urine)
Excessive sweating
Fatigue
Weakness
Thyroid problems

 

OTHER SYSTEMS YES NO
ENT (ears, nose, throat)
Integumentary (skin)
Lymphatic
Psychiatric
Musculoskeletal
Goals for Physical Therapy (examples: climb stairs, get out of a car easier, increase walking time, return to
prior activities)
  
Please tell us how you heard about us  


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