OUTPATIENT SERVICES – INTAKE QUESTIONNAIRE

To ensure you receive a complete and thorough evaluation, please provide us with the important background information on the
following form. If you do not understand a question, leave it blank and your therapist will assist you. Thank you!

Patient Name: __________________________________ Date:__________________________

Allergies: List any medication you are allergic to : ___________________________________________________________________

Are you latex sensitive?     yes    no    List any other allergies we should know about: ________________________________________

Are you under the care of a(n) ( please check all that apply )
  Medical Doctor          Osteopath             Psychiatrist / Psychologist            Other: ______________________________
  Dentist                  Chiropractor         Physical Therapist                   Date of last physical exam: ___________
If you have seen any of the above in the past 3 months, please describe the reason ( illness, medical condition, Physical, etc ):

Please list any significant injuries or other conditions for which you have been treated, including the approximate date and reason
  Date                                Reason                             Date                             Reason

Please list any surgeries or other conditions for which you have been hospitalized, including the approximate date and reason .
  Date                              Reason                             Date                            Reason

Have you ever been diagnosed with any of the following conditions? (Please check all that apply)
  High Blood Pressure                          Other arthritic conditions                    Multiple Sclerosis
  Circulation Problems                         Depression                                    Thyroid Problems
  Asthma                                       Hepatitis                                     Diabetes
  Chemical Dependency (e.g. alcoholism)        Tuberculosis                                  Osteoporosis
  Rheumatoid Arthritis                         Stroke                                        Blood Clots
  Kidney Disease. If yes, what kind?
  Cancer. If yes, what kind?
  Heart Problems. If yes, what kind ?

During the past month, have you been feeling down, depressed or hopeless ?          yes         no
During the past month, have you been bothered by having little interest or pleasure in doing things?               yes     no
Do you ever feel unsafe at home or has anyone hit you or tried to injure you in any way ?      yes                no

Please list any prescribed medications including pills, injections, patches and over-the-counter medications
   See attached medication list:

Have you taken any of the following in the past week? (Please check all that apply)
  Aspirin          Tylenol         Motrin                  Anti- inflammatory                   Vitamin / Mineral supplements
  Ibuprofen        Advil            Herbal remedies        Heartburn/ ulcer medication          Others: _______________________

                  OP Intake Questionnaire
                  Doc # 128160v1 Rev. 12/08

How much caffeinated coffee or other caffeinated beverages do you usually drink per day? _______________________
Do you smoke? yes          no How many packs per day ? ______ For how many years?_______ If you quit, when?_________
How many days a week do you drink alcohol? _____________________________________________________
If 1 drink equals 1 beer or glass of wine, how much do you usually drink at a time? ____________________________

                                                      Prior level of function
 Successfully complete basic self care skills?       Yes, No. Specify:___________________________________________

 Successfully complete cooking, cleaning and other homemaking tasks?            Yes,     No. Specify: _____________________

 Active outside the house such as shopping and going to church?         Yes,     No. Specify: ___________________________

 Engage in volunteer / work activities?       Yes,    No. Specify: ________________________________________________

 Please mark an “ X” on the location of your pain                                      Pain
                                                         Rate your pain on a 0-10 scale; 0 being none and 10 being worst

                                                         Best ___/ 10
                                                         Average ___/ 10
                                                         Worst ___/ 10

                                                         What makes your pain worst?
                                                         What makes your pain better?
                                                         Please check one:
                                                                    My pain is always there ( continuous )
                                                                    My pain comes and goes ( intermittent )

                          Please check any of the following that are NEW, UNUSUAL, or ATYPICAL of you.
   Weight loss or change ( circle one)               Joint/ muscle swelling               Nausea/ Vomiting
   Easy bruising                                     Dizziness/ lightheadedness           Excessive bleeding
   Fatigue                                           Weakness                             Difficulty breathing
   Regular cough                                     Fever/ chills/ sweats                Numbness or tingling
   Arm/ leg swelling                                 Tremors                              Difficulty swallowing
   Seizures                                          Heart racing in your chest           Heartburn/ indigestion
   Double Vision                                     Blood in stools                      Constipation/ diarrhea
   Loss of vision                                    Eye redness                          Skin rash
   Post menopause                                    Problem sleeping                     Blood in urine
   urinary incontinence                              Sexual difficulties                  Night sweats
   Pregnant or think you may be pregnant             Hearing problems                     Stress at home
   Problems urinating ( difficulty starting, painful, etc. )

Name of person completed this form:                                  Relationship to patient:

Signature of patient:

                 OP Intake Questionnaire
                 Doc # 128160v1 Rev. 12/08

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