Physical Therapy Pre-Exam Questionnaire
Client Name:
*
Please indicate the location of your symptoms on the body diagram
Check your symptoms
Rows
Yes
Aching
Constant
Sharp/Stabbing
Intermittent
Numbness
Tingling
Burning
Other
Please rate your worst pain in the last couple days, 0-10 (10 is the worst)
Please rate your best pain in the last couple days, 0-10 (10 is the worst)
What is your age?
What caused your pain or problem?
Approximately when did it start?
Is it getting worse, better, or staying the same?
Have you ever had this pain or problem before?
Are any of your everyday activities affected?
List all past surgeries with dates
List all medical conditions you have or were told you have
Please provide a list of all your current medications
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