Initial Medical Evaluation Form printable pdf download

DOB______________

INITIAL EVALUATION

Subjective:

Name:__________________________________________Date____________________Age:______________

Physician:______________________________Diagnosis:__________________________________________

Occupation:_____________________________Sport/Activity:_____________________________________

Physical Demands of the job?________________________________________________________________

Please circle which body part you are seeking treatment:

Left

Right

Neck Mid Back Low Back Shoulder Elbow Hand/Wrist Hip Knee Ankle/foot

Other_____________________________________________________________________________________

Date of injury:_____________

Date of Surgery:____________

What caused your injury or problem?_________________________________________________________

__________________________________________________________________________________________

What is your chief complaint?________________________________________________________________

Have you had similar occurrences in the past?__________________________________________________

__________________________________________________________________________________________

Have you had previous treatment? What kind?__________________________________ When:_________

Circle recent tests- MRI Xrays CT Scan Bone Scan EMG Other_______________________________

Medical History (Circle) High Blood Pressure, Diabetes, Arthritis, Osteoporosis/penia, Cancer, Allergies,

Heart condition, Pace Maker, Stroke, Pregnancy, cortisone injections

Other including orthopedic conditions and surgeries:_______________________________________________

__________________________________________________________________________________________

Current Medications-_______________________________________________________________________

__________________________________________________________________________________________

Pain rating:

Indicate your usual level of pain by circling the appropriate number on the scale:

Worst Pain=________

Least Pain=________

0____1____2____3____4____5_____6____7____8____9____10

mild

moderate

extreme agony

Does your pain?(circle) Throb Burn Stab Ache Other_______________________________________

Is your pain constant? Yes

TURN PAGE OVER

Initial Medical Evaluation Form