SC Sports Therapy Patient Intake

SC Sports Therapy Patient Intake

Name: ______Date: ______

Address:______City: ______State: ____ Zip: ______

Phone: Home______Work______Ext. ______Cell ______

Age:______Date of Birth: ______Sex: ______Social Security #:______

Email Address:______Employer:______

Occupation: ______How did you hear about us? ______

Were you injured in an accident/auto accident? Yes / No Do you have insurance? Yes / No

Past Health Habits:

Have you…? / Yes / No / Explain Briefly if Yes
…been hospitalized in the last 5 years?
…had any mental disorders?
…had any broken bones?
…had any strains or sprains?
Do you ever take minerals, herbs or vitamins?
How is most of your day spent? Standing? Sitting? Other?
How old is your mattress?
When was your last physical exam?

Health Habits:

Yes / No / If ‘Yes’, how long or how much per week?
Do you exercise?
Do you smoke tobacco?
Now or in the past?
Do you drink alcohol?
Do you use recreational drugs?
Do you drink coffee, soda, or black tea?
Do you drink ‘diet’ soda or eat ‘diet’ foods?
Do you follow any dietary modifications? / If yes, please describe:

Height______Weight: ______Blood Pressure: ______/______

Health History: if any blood relatives has had any of the following conditions, please circleand list which relative(s)

Alcoholism / Diabetes / High Cholesterol
Anemia / Emphysema / Multiple Sclerosis
Arteriosclerosis / Epilepsy / Osteoporosis
Arthritis / Heart Attack / Sclerosis
Asthma / Heart Disease / Stroke
Cancer / High Blood Pressure / Thyroid Disease

Do you have any other health issues or concerns that our staff should be made aware of? ______

Current Condition:

Give a brief detailed description of the problem you are currently experiencing? ______

How long have you had this condition? ______

Is it getting worse? Yes/ No? Does it bother you ⃝ at work ⃝ asleep ⃝other ______

What seemed to be the initial cause? ______

Please leave SHADED area for doctor to fill out. Thank you!

Range of Motion / Cervical / Dorso-Lumbar / Diagnosis
(P)ain (R)adiculitis / Norm / Actual / Actual / Norm / Main Code / Pain in-
Flexion / 55 / P R / P R / 90 / 723.1 C / Ankle/Foot
Extension / 45 / P R / P R / 30 / 724.1 T / Elbow/Arm
Left Lat.Flexion / 45 / P R / P R / 30 / 724.2 L / Hip/Thigh
Right Lat. Flexion / 45 / P R / P R / 30 / 724.3 S / Shoulder
Left Rotation / 80 / P R / P R / 30 / Knee/Leg
Right Rotation / 80 / P R / P R / 30 / 729.1 M / Wrist/Hand
Orthopedic Tests / L / R / L / R / Reflex / L / R
Compression 0” / Straight Leg / Biceps
Compression 15” / Braggard / Triceps
Soto Hall / Lasegue Sign / Radial
Shoulder Depression / Dbl Leg Raise / Patellar
Adsons / Kemps / Achilles
Distraction / Patricks
Georges / Elys

Doctors Notes:______