We Are Special Because We Care
Exercises on

New Patient Form

Dear Patient / Client,
We are about you.
We take your issues seriously and thoroughly. We comprehensively assess of your pain history, life situations, health and eating habits, etc. Please be patient in filling out this form as thoroughly as you can to help us help you. Skip what you don’t think is relevant.

On our first meeting, please expect that it will take longer, about 1.5 hours for us to get your full information. We will explain in depth as much as we can how we plan to help you. The subsequent visits will be less paperwork and more direct hands-on care.

Come to the sessions with comfortable flexible clothing. You might have to remove part of your clothing if we need to assess the skin, bones, muscles in certain areas. Be ready to remove your shoes and socks as needed. Always let us know if you are uncomfortable with any situation or requests and we will respect your concerns.

Have a nice harmonious day!
Ginger and staff

(*) = Required
Patient Information
Gender: Male       Female
Are you here for a Functional Capacity Evaluations?    YES    NO
Purpose of FCE: chose any or all of these:
   To determine general abilities/ limitations
   To qualify for disability
   To match employment - to return to work
Are you here under Workman's Compensation:    YES    NO
  Date started on Workman's Compensation:
  Case Workman's Comp number:
  Case manager First, Last, Phone, Fax:
  Case Management Company:
Employer Name:
Employment Status:
Job title:
Job description:
Last Employer name if not working currently:
What are/were your main tasks:
What are your limitations to working right now:
Emergency Contact 1
First Name:  
Last Name:
Phone Number 1:
Phone Number 2:
Patien'ts main caregiver: Yes / No
Does patient live with this person? Yes / No
Emergency Contact 2
First Name:  
Last Name:
Phone Number 1:
Phone Number 2:
Patien'ts main caregiver: Yes / No
Does patient live with this person? Yes / No
Emergency Contact 3
First Name:  
Last Name:
Phone Number 1:
Phone Number 2:
Patien'ts main caregiver: Yes / No
Does patient live with this person? Yes / No
List of your Physicians
   YES    NO
Primary Care Physician (PCP):
First Name:
Last Name:
Referring Physician:
List of Physicians: Remove  
First Name:
Last Name:
Name of Group Practice:
  Add more
DME Representative:
Name of Representative:
Other not listed:

Other Provider:

Please list the website(s) in which you found us:
Did you see our Website at or if so, what did you think of our website:
What is the Medical Condition/Diagnosis that you are most concerned about?
If Spinal Cord Injury, what level? When were these diagnoses made?
PT Diagnoses /codes:
  • General
    • Disorder of muscle, unspecific
    • Fibromyalgia
    • Muscle weakness (generalized)
    • Myalgia
    • Myositis, unspecified
    • Other symptoms and signs involving the musculoskeletal system
  • Neck, Trunk and Back
    • Cervical disc disorder with myelopathy, unspecified cervical region
    • Cervicalgia (pain in cervical neck)
    • Chest pain, unspecified
    • Dorsalgia, unspecified (backache)
    • Low Back Pain
    • Other intervertebral disc degeneration, lumbar region
    • Other intervertebral disc degeneration, lumbosacral region
    • Other intervertebral disc displacement, lumbar region
    • Other intervertebral disc displacement, lumbosacral region
    • Other specified deforming dorsopathies, site unspecified
    • Other specified disorders of temporomandibular joint
    • Pain in thoracic spine
    • Postural kyphosis, site unspecified
    • Temporomandibular joint disorder, unspecified
    • Torticollis
    • Unspecified abdominal pain
    • Unspecified thoracic, thracolumbar and lumbosacral intervertebral disc disorder
  • Shoulder and UE
    • Calcific tendinitis of unspecified shoulder
    • Impingement syndrome of unspecified shoulder
    • Other shoulder lesions, unspecified shoulder
    • Pain in arm, unspecified
    • Pain in L arm
    • Pain in L shoulder
    • Pain in R arm
    • Pain in R shoulder
    • Pain in unspecific limb
    • Pain in unspecified elbow
    • Pain in unspecified finger(s)
    • Pain in unspecified hand
    • Pain in Unspecified shoulder
    • Pain in unspecified wrist
    • Strain of unspecified muscle, fascia and tendon at wrist and hand level, unspecified hand, initial encounter
    • Unspecified sprain of unspecified wrist, initial encounter
  • Hip and LE
    • Pain in L ankle and joints of L foot
    • Pain in L hip
    • Pain in L knee
    • Pain in L leg
    • Pain in leg, unspecified
    • Pain in R ankle and joints of R foot
    • Pain in R hip
    • Pain in R knee
    • Pain in R leg
    • Pain in unspecific limb
    • Pain in unspecified ankle and joints of unspecified foot
    • Pain in unspecified hip
    • Pain in unspecified knee
  • Gait
    • Ataxia, unspecific (poor coordination of limb)
    • Ataxic gait
    • Difficulty in walking, not elsewhere classified
    • Other abnormalities of gait and mobility
    • Paralytic gait
    • Unspecific lack of coordination
    • Unspecified abnormalities of gait and mobility
  • Neurological Disease/Disorders (Peds and Adult)
    • Autistic Disorder
    • Bell's Palsy
    • Cerebral palsy, unspecified
    • Congenital myopathies
    • Delayed milestone in childhood
    • Down syndrome, unspecified
    • Multiple Sclerosis
    • Muscular dystrophy
    • Paraplegia, unspecified
    • Quadriplegia, unspecified
    • Spastic hemiplegia affecting left dominant side
    • Spastic hemiplegia affecting right dominant side
    • Spastic hemiplegic cerebral palsy
    • Spastic quadriplegic cerebral palsy
    • Unspecified lack of expected normal physiological development
  • Nerve disorders
    • Carpal tunnel syndrome, unspecified upper limb
    • Radiculopathy, lumbar region
    • Radiculopathy, lumbosacral region
    • Radiculopathy, thoracic region
    • Radiculopathy, thoracolumbar region
    • Disorder of male genital organs, unspecified
    • Dyspareunia
    • Dysuria
    • Endometriosis, unspecified
    • Frequency of micturition
    • Full incontinence of feces
    • Incomplete defecation
    • Interstitial cystitis (chronic) with hematuria
    • Interstitial cystitis (chronic) without hematuria
    • Low back pain
    • Mixed incontinence
    • Nocturia
    • Nocturnal Enuresis
    • Other specific conditions associated w/female genitalia and menstrual cycle
    • Other specified conditions associated with female genital organs and menstrual cycle
    • Other specified conditions associated with female genital organs and menstrual cycle
    • Other specified urinary incontinence
    • Overactive bladder
    • Overflow incontinence
    • Pelvic and perineal pain
    • Retention of urine, unspecified
    • Stress incontinence (female) (male)
    • Urge Incontinence
  • Constipation
    • Outlet dysfunction constipation
    • Slow transit constipation
  • Muscular
    • Abdominal Hernia
    • Contracture of muscle, unspecified site
    • Diastasis Recti
    • Muscle wasting and atrophy, not elsewhere classified, unspecified site
    • Other muscle spasm
    • Separation of muscle (nontraumatic), unspecified site
  • Pelvic Organ Prolapse
    • Cystocele, midline
    • Cystocele, unspecified
    • Uterovaginal prolapse, unspecified
    • Vaginal enterocele
  • TMJ
    • TMJ Articular disc disorder
    • TMJ Myalgia/myofascial pain syndrome
    • TMJ Synovitis
  • Pain / Disorder
    • Abdominal Pain 789.0
    • Ankle/Foot pain719.47
    • Autistic Disorder 299.0
    • Back pain 724.5
    • Back-Lower pain 724.2
    • Balance 781.3
    • Bell's Palsy 351.0
    • Carpal Tunnel 354.0
    • Cerebal Palsy (CP) 343.9
    • Cervicalgia (neck pain) 723.1
    • Degenerative Joint Disease 722.2
    • Degenerative LS and LB 722.52
    • Developmental Delay 783.4
    • Diabetic Neuropathy - 250.6
    • Difficulty Walking (All) 719.7
    • Down's Syndrome 758.0
    • Forearm pain719.42
    • Gait (Abnormal) 781.2
    • Gout 719.67
    • Groin/ Flank Pain 789.0
    • Hand pain 719.44
    • Hemiplegics 343.1
    • Hip pain 719.45
    • Impingement Shoulder 726.2
    • Incoordination Muscular 781.3
    • Intervertebral Cerv.disc. DO w/ myelopathy cervical region 722.71
    • Knee pain 719.46
    • Leg pain 729.6
    • Lumbago 724.2 (Back Pain)
    • Lumbar Strain 722.10
    • Multiple Sclerosis - 340.0
    • Multiple Sclerosis – congenital 359.0
    • Muscular Dystrophy - 359.1
    • Myasthenia Gravis - 358.0
    • Neck pain (see cervicalgia) 723.1
    • Paraplegia 344.1
    • Quad CP 343.2
    • Quadriplegia – Unspecified 344.0
    • Radiculitis LB and Leg 724.4
    • Sclerosis 340
    • Scoliosis 7378
    • Shoulder pain 719.41
    • Spinal bifida
    • Spinal Cord Injury - 741.9
    • Stroke- CVA - 436.0
    • Torticollis 723.5
    • Traumatic Brain Injury - 854.0
    • Upper-arm 719.42
    • Walking Difficulty (tip-toe walking) 719.7
    • Weakness 728.9 (Muscle Weakness 728.87)
    • Wrist Joint pain 719.43
  • Pelvic Floor
    • Constipation
      • Outlet Obstruction 564.02
      • Slow Transit 564.01
    • Incontinence
      • Fecal 787.6
      • Nocturnal Enuresis 788.38
      • Stress Incontinence - Female 625.6
      • Stress Incontinence - Male 788.32
      • Urinary Mixed 788.33
      • Urinary Urge 788.31
    • Muscular
      • Diastasis Recti 728.84
      • Pelvic Floor Spasm 728.85
      • Pelvic Floor Weakness 728.2
    • Pain
      • Dyspareunia 625.0
      • Endometriosis 617.9
      • IC 595.1
      • Myofascial 729.1
      • Pelvic Pain - Female 625.9
      • Pelvic Pain - Male 608.9
      • Vulvodynia 625.8
    • Pelvic Organ Prolapse
      • Cystocele 618.01
      • Enterocele 553.9
      • Rectocele 618.6
      • Utero/Vaginal 618.4
      • Vaginal 618.0
    • Urinary Tract
      • Dysuria 788.1
      • Frequency 788.41
      • Nocturia 788.43
      • OAB 596.51
      • Retention of Urine 788.20
  • Other
    • 844.8 Sprain of knee
    • 846.0 Lumbosacral (ligament) sprain
Other dx not listed:
Have you had a seizure in the last 6 months? yes         no
If you answered yes, what was the date of the seizure?
What is your reason for visit?
  Add more

Tell me about your pain (including when it started, where, treatment you received)

All the time    Occasionally    Intermittently    No
Please describe your pain the best you can for each body part. Try to analyze your pain to understand how it affects you.
Explain below individually, or if all body parts hurt the same then you can answer just once:
Where are you having pain?
List body part (s): Remove  

From where to where ?
Stays in one place    Spreads out    Moves around    Radiating (to where?)
Sharp Shooting    Aching    Burning    Numbness    Tingling   Discomfort
When did you start having pain in this (these) area (s)?

0 NO PAIN 1 2 3 4 5 6 7 8 9 10 WORST pain as if you would need to go to the emergency room
WORSE BETTER SAME Gets better but would return
Movements Changing positions SITTING STANDING WALKING
Bending down Reaching up Lying down COLD HEAT
Rubbing/ Massage the area Heating ointments Medications
Movements changing positions SITTING STANDING WALKING
Bending down Reaching up Lying down COLD HEAT
Rubbing/ Massage the areas Heating ointments Medications
List another body part
Other explanations about Pain:

List by year (example 2002-8-22: S/P mastectomy, 2004 Total knee replacement, result is still having swelling, or completely healed, no problem)
Year Procedure body part if needed to elaborate, Right or Left side Result of this procedure
Add More
List of Medications: Remove  
Name of Medication:
Dosage in mg
Start date:
End date:
Pharmacy Name:
Phone #:
  Add more
Past PT programs: Remove
Clinic name:
Dates of:
  Add more

Precautions: Is there anything we need to be careful about while working with you for your safety? Example: heart condition, dizziness, falling, fear, ADHD, lacking attention, distractability, anxiety, hip precautions, fall precautions, wounds, open skin, easy bruising, etc.
Ht Wt: lb
Cardiovascular/ Pulmonary status (intact/impaired):
Check symptoms you currently have or have had in the past year


Chills    Depression    Dizziness    Fainting    Fever    Forgethulness    Headache    Loss of sleep    Loss of weight    Nervousness    Nurnbness    Sweats


Appetite poor    Bloating    Bowel changes    Constipation    Diarrhea    Excessive hunger    Excessive thirst    Gas    Hernorrhoids    Indigestion    Nausea    Rectal bleeding    Stomach pain    Vomiting    Vomiting blood


Bleeding gums    Blurred vision    Crossed eyes    Difficulty swallowing    Double vision    Earache    Ear discharge    Hay fever    Hoarseness    Lossof hearing    Nosebleeds    Persistent cough    Ringing in ears    Sinus problems    Vision - Flashes    Vision - Halos

WOMEN only

Abnormal Pap Smear   Bleeding between periods   Breast lump   Extreme menstrual pain   Hot flashes   Nipple discharge   Painful intercourse   Vaginal discharge   Other   Date of Last Menstrual Period:
Date of Last Papsmear:
Have you had a Mammogram?   Yes       No
Are you pregnant?   Yes     No     Not sure:

Number of Children:  

MUSCLE/JOINT /BONE (Pain, weakness, numbness in:)

Arms    Back    Feet    Hands    Hips    Legs    Neck    Shoulders


Chest pain    High blood pressure    Irregular heart beat    Low blood pressure    Poor circulation    Rapid heart beat    Swelling of ankles    Varicose veins


Bruise easily   Hives   Itching   Change in moies   Rash   Scars   Sore that won't heal

MEN only

Breast lump   Erection difficulties   Lump in testicles   Penis discharge   Sore on penis   Other


Blood in urine    Frequent urination    Lack of bladder control    Painful urination

Check conditions you currently have or have had in the past year
  • AIDS   
  • Alcoholism   
  • Anemia   
  • Anorexia   
  • Appendicitis   
  • Arthritis   
  • Asthma   
  • Bleeding Disorders  
  • Breast Lump   
  • Bronchitis   
  • Bulimia   
  • Cancer   
  • Cataracts   
  • Chemical Dependency   
  • Chicken Pox   
  • Diabetes   
  • Emphysema   
  • Epilepsy   
  • Glaucoma   
  • Goiter   
  • Gonorrhea   
  • Gout   
  • Heart Disease   
  • Hepatitis   
  • Hernia   
  • Herpes   
  • High Cholesterol   
  • HIV Positive   
  • Kidney Disease   
  • Liver Disease   
  • Measles   
  • Migraine Headaches   
  • Miscarriage   
  • Mononucleosis   
  • Multiple Sclerosis   
  • Mumps   
  • Pacemaker   
  • Pneumonia   
  • Polio   
  • Prostate Problem   
  • Psychiatric Care   
  • Rheumatic Fever   
  • Scarlet Fever   
  • Stroke   
  • Suicide Attempt   
  • Thyroid Problems   
  • Tonsillitis   
  • Tuberculosis   
  • Typhoid Fever   
  • Ulcers   
  • Vaginal infections   
  • Venereal Disease   
  • Frequent Urinary Infections   
Others Medical History/problems NOT listed above/ Explanations:

Sensible conversations
Caution while driving,   wheelchair     Vehicel
Makes good judgment as he drove at day     night.
Works: Full time     Part time     Temporary
Do you go to school? Yes       No
How many hours/week?
Name of school:
Grade level:
Special classes/ IEP?
Working toward a degree?
Day / Week

(include any types of exercise, fun activities, exercise styles, or exercise equipment that you use)
yes         no
Check box if you are here for a Driving Evaluation and Behind the Wheel/ On the Road Training
Mobility Skills:
Home Environment:

Do you have any of the following Home Services?

1 Home Health Care
2 Home RN (Nurse)
3 Home Health Aides
4 Home Health Therapies (PT, OT, ST)
5 Home IV
6 Diabetes Care
7 Wound Care
8 Colostomy or Supplies Delivered
9 Any Home Equipment Delivery
10 Home Companions
11 Any other services done at home

What would you like to see happen when you work with us?