East End Physical Therapy
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For Patients
Staff
Services
Contact
East End Physical Therapy
Name:
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First Name
Last Name
Date of Birth :
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DD
YYYY
Sex:
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Select One
Male
Female
Phone:
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(###)
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Alternate Phone:
(###)
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Address:
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact Name:
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Emergency Contact Number:
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(###)
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Primary Care Doctor:
Primary Care Doctor Contact Number:
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Insurance Information
Insurance:
*
Member ID Number:
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Past Surgeries
Please list and date your past surgeries:
Current Medications
Please list your current medications (prescription, over the counter):
Past Medical History
Have you ever been told you have any of the following?
Check all that apply
Cancer
Heart Problems
High Blood Pressure
Angina/Chest Pain
Diabetes
Osteoporosis/Osteopenia
Thyroid Problems
Rheumatoid Arthritis
Osteoarthritis
Depression
Blood Clots
Infectious Diseases
Lung Problems
Hepatitis
Anemia
Allergies
Fibromyalgia
Kidney Disease
Stroke
Seizures/Epilepsy
Are you currently experiencing any of the following?
Check all that apply
Fever/Chills/Sweats
Numbness/Tingling
Dizziness
Poor Balance (Falls)
Shortness of Breath
Night Pain
Pelvic Pain
Headaches
Unexplained Weight Loss
Depression
Current History
Do you have a pacemaker?
*
Yes
No
Are you pregnant?
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Yes
No
Are you a somker?
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Yes
No
What body part/diagnosis brings you to seek Physical Therapy?
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What date (approximately) did your present symptoms start?
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MM
DD
YYYY
How did your symptoms start?
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Gradually
Suddenly
Injury
Surgery
How have your symptoms changed?
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Getting better
About the same
Getting worse
What makes your symptoms better?
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What makes your symptoms worse?
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Hav you had any X-Ray, MRI or other testing for this problem?
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Yes
No
What treatments have you received for this problem so far?
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How did you hear about us?
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Thank you!