Name: ____________________________________Home Phone: _____________________Work Phone: _____________________

Email Address: _____________________________________________________________Cell Phone: ______________________

Home Address: ____________________________________City: _____________________________ Zip Code: _______________

Primary Place of Residence: ________________________ Date of Birth: _____________________ Male Female

Height _______________ Weight _______________Age___________ Occupation _______________________________________

Marital Status: Single Married Divorced Other_____ Spouse’s Name _____________________Spouse WK# _________

Nearest Relative not living with you: _________________________________________________Phone: ______________________

Nearest Friend not living with you: __________________________________________________Phone: ______________________

Primary Physician: _____________________________________________________________ Phone: ______________________

Referring Physician: ____________________________________________________________Phone: ______________________

Person to contact in case of Emergency:

Name: ____________________________________ Relationship: _______________________ Phone: ______________________

Whom may we thank for referring you to us? __________________________________________ Phone: ______________________

Have you received home health care within the past 12 months? Yes No

Have you had any Physical, Occupational, or Speech Therapy this year? Yes No

Are you being treated for injuries sustained in an automobile accident? Yes No

Does your physician know you are participating in this exercise program? Yes No

I authorize appointment confirmations by text/email, if available Yes No

Who will be responsible for payment rendered upon services? _________________________________________________________

I acknowledge that I have been informed of premier therapy solution’s privacy practices as required by the health insurance portability and
accountability act (HIPPA). I further acknowledge that I have been presented with a brochure outlining these practices.

I understand and agree that (regardless of my insurance status), I am ultimately responsible for the balance of my account for any professional
services rendered. I have read all the information on this sheet and have completed the above answers. I certify this information is true and
correct to the best of my knowledge. I will notify you of any changes in my status or the above information.

Signature ______________________________________________________________ Date _____________________________

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Name ___________________________________________Age__________________________Date_______________________

Please describe your current complaint or limitation: ________________________________________________________________

Please describe how your problem began: ________________________________________________________________________

Please tell us when your condition started: _______________________________________________________________________

List tests or other interventions for this condition that you have had: _____________________________________________________

Please indicate the daily activities that you cannot perform: ___________________________________________________________

Please indicate your level of functioning prior to the onset of this condition: _______________________________________________

Describe any physical activity you do somewhat regularly _____________________________________________________________

Please inform us of any environmental or living condition that you may have difficulties with: ___________________________________

Did you have surgery? Yes No Date____________ Procedure: _______________________________________

______________________________________________________________________________________________________

Are you taking any medications or drugs? If so, please list medication, dose and reason. ______________________________________

______________________________________________________________________________________________________

Please describe the nature of your pain:

Sharp Pain
Dull (Pain) Ache
Throbbing
Numbness
Shooting
Burning
Tingling

Please describe the frequency of your pain:

Constant (76 – 100%)
Frequent (51 – 75%)
Occasional (26 – 50%)
Intermittent (25% or less)

<< MARK ON THE PICTURE WHERE YOU HAVE PAIN OR OTHER SYMPTOMS.

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Indicate the intensity of your pain at rest: (No Pain) 0 1 2 3 4 5 6 7 8 9 10 (Unbearable Pain)

Indicate the intensity of your pain with movement: (No Pain) 0 1 2 3 4 5 6 7 8 9 10 (Unbearable Pain)

Since this condition began your symptoms have: decreased not changed increased

Your symptoms are worse in morning afternoon night increased during the day same all day

Activities or positions that increase symptoms: _____________________________________________________________________

Activities or positions that decrease symptoms: ____________________________________________________________________

If you have ever had a listed condition in the past, please check it in the PAST column. If you are presently troubled by a particular condition,
check it in the PRESENT column. The information you provide concerning past and present conditions and diseases assists your therapist in
more thoroughly understanding your state of health.

PAST PRESENT
High Blood Pressure (401.9)
High Cholesterol
Heart Attack (410.9)
Stroke (436)
Asthma / Lung Disease(493.9)
HIV / AIDS (042)
Cancer (199.1) Location: ______Date: ___________
Tumor (229.9)
Systemic Lupus (710.0)
Hepatitis
Epilepsy (349.5)
Diabetes (250.0)
Rheumatoid Arthritis (714.0)
Arthritis (716.9)
Pregnancy
Tobacco (305.1) packs/day __________________
Drug or Alcohol Dependence (303.9)
Diabetes or thyroid condition
Obesity (more than 20% over ideal body weight)
Hernia, or any condition aggravated by lifting weights
Vertigo or Dizziness
Spinal Stenosis
Osteoporosis or Osteopenia
Scoliosis
Angina (413.9)
Sciatica / Back Problems
Other __________________________________
Please provide detail for the answers above:

______________________________________________________________________________________________________

______________________________________________________________________________________________________

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