Physical Therapy/balance Therapy Form

PHYSICAL   T HERAPY/BALANCE   T HERAPY   F ORM  

 

Name:_________________________________________________________         D ate:________________________    

 

What   i s   y our   c hief   c omplaint?   _ _________________________________________________________________________________  

 

When   d id   i t   s tart?________________________________________________________________________________________________  

 

Is   i t   d ue   t o   a n   i njury,   f all,   o r   a ccident?   _ ________________________________________________________________________  

 

Is   y our   c ondition   r esulting   i n   a   w orker’s   c ompensation   c laim?     _ ____________________________________________  

   

If   s o,   i s   a   l awyer   i nvolved?   Yes    

No  

 

Have   y ou   h ad   a ny   o ther   t reatments   f or   t his   c ondition   ( currently   o r   i n   t he   p ast)?  

Yes  

No  

  Please   e xplain   _ _________________________________________________________________________________________________  

 

If   b alance   i s   a n   i ssue,   h ave   y ou   f allen?  

Yes    

No  

   

If   y es,   h ow   o ften   h ave   y ou   f allen   i n   t he   p ast   w eek:   _ _________   o r   m onth:   _ _________or   y ear:_________  

   

Do   y ou   h ave   d izziness?  

Yes  

No     _ ______________________________________________________________    

 

PAIN   S CALE:  

 

If   y ou   a re   e xperiencing   p ain,   p lease   m ark   o n   t he  

diagram   t o   t he   l eft   w here   y ou   a re   e xperiencing   p ain.  

 

On   a   s cale   o f     0 -­‐   1 0   ( 0=   n o   p ain,   1 0=emergency   r oom  

pain),   h ow   w ould   y ou   r ate   y our   p ain:  

 

Now:   _ _____           A t   w orst:   _ ______     A t   b est:   _ ______    

 

Circle   t he   i tems   t hat   d escribe   t he   n ature   o f   y our   p ain:  

      s harp      

dull  

piercing    

shooting  

      a ching    

deep  

superficial  

tingling  

      b urning  

numb   intermittent    

constant  

      s tabbing  

 

What   m akes   y our   p ain   w orse   _ ____________________________  

 

What   m akes   i t   b etter   _ ______________________________________  

 

Is   y our   p ain:     i mproving       w orsening         c onstant  

 

 

Is   t here   a nything   e lse   t hat   y ou   f eel   w e   s hould   k now   a bout   t o   g ive   y ou   q uality   c are?   _ _____________________  

_____________________________________________________________________________________________________________________  

 

So   w e   c an   b est   s erve   y ou,   p lease   l ist   y our   g oals   f or   t herapy   _ _________________________________________________  

______________________________________________________________________________________________________________________    

 

 

 

Signature   o f   P atient/Guardian   _ ____________________________________________________   D ate:   _ __________________    

                                                                                                                                                                           

 

 

 

The   B alance   C enter   a t   T allgrass  

601   S W   C orporate   V iew,   S uite   2 20  

Topeka,   K S   6 6615  

785-­‐228-­‐6100