Patient Summary Form Page 2
ADVERTISEMENT
1
2Date _____________________________
SOCIAL HISTORY:
I
Occupation: ____________________________________
I
Retired
With whom do you live? ____________________________
Married:
I
Yes
I
No
Children:
I
Yes
I
No
If you have children, how many? _________
Where do you live?
I
House
I
Apartment How many stories? ______ How do you enter?
I
Stairs
I
Ramp
If you have stairs to enter home, how many? ______
Railing? Right / Left / Both sides / None / Other: ____________________
If you have stairs inside the home, how many? ______
Railing? Right / Left / Both sides / None / Other: ____________________
Do you exercise:
I
Yes
I
No
What type and how often? _________________________________________________________
I
I
I
I
Tobacco Use:
Yes
No
If yes,
Smoke
Chew How much/often? ____________________________
Alcohol Use:
I
Yes
I
No
If yes, how much/often? ____________________________
FALLS:
I
Not Applicable
I
I have fallen _____ times in the past year.
I
Yes, I have a fear of falling.
I
I
I have fallen _____ times in the past 3 months.
I have fallen _____ times in the past 6 months.
What are you coming to therapy for today?
PAIN DIAGRAM
Please mark the area of injury or discomfort on the chart below.
____________________________________________________
When did your symptoms begin?
____________________________________________________
Have you ever received Physical / Occupational / Speech Therapy
for this condition?
I
Yes
I
No
If yes, explain: ________________________________________
____________________________________________________
____________________________________________________
Pain?
I
Yes
I
No
How do you treat it?
____________________________________________________
____________________________________________________
If you have pain, what makes it worse? What makes it better?
Please circle the number that reflects your pain.
____________________________________________________
____________________________________________________
No 0 1 2 3 4 5 6 7 8 9 10 Worst
____________________________________________________
Pain
Pain Possible
What are your goals for therapy?
How do you best learn (select all that apply)?
I
Seeing
I
Doing
I
Hearing
I
Reading
I
Other: ________________________
________________________________________________ ____________ ________________
Patient Signature or Person Authorized to Consent on Behalf of the Patient
Date
Time
FOR PENN THERAPY & FITNESS THERAPIST ONLY: I have read and reviewed this Patient Summary Form
Therapist Name/Signature: ________________________________/________________________________ Init_____ _____ /____ /_____ _____:_____AM/PM
Date
Time
Therapist Name/Signature: ________________________________/________________________________ Init_____ _____ /____ /_____ _____:_____AM/PM
Date
Time
Therapist Name/Signature: ________________________________/________________________________ Init_____ _____ /____ /_____ _____:_____AM/PM
Date
Time
Therapist Name/Signature: ________________________________/________________________________ Init_____ _____/____ /_____ _____:_____AM/PM
Date
Time
DO NOT USE UNAPPROVED ABBREVIATIONS
Page 2 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical