5006 Veterans Highway
Holbrook NY 11741
Phone: 631-416-6926
Fax: 631-218-8656
Date:________________________________
PATIENT INFORMATION:
Last Name:____________________________________________________________First Name:___________________________________________________________
Address:________________________________________________________________Sex:_______________Email:____________________________________________
City:__________________________________________________________________State:_____________________________Zip Code:____________________________
Phone (H):______________________________________________(W)________________________________________(C)______________________________________
Date of Birth:______________________________________________________Marital Status:_______________ SS#:______________________________________
Employer Name:______________________________________________________________________________________________________________________________
Employer Address:___________________________________________________________________________________________________________________________
Who referred you to Max Effort Physical Therapy?_________________________________ Reason for visit:___________________________________
Primary Care Physician Name & Phone #:__________________________________________________________________________________________________
Person to contact incase of an emergency:____________________________________________________Phone #:___________________________________
INSURANCE INFORMATION:
Primary Insured Name:___________________________________________________________________________DOB:_____________________________________
Relationship to Patient:_________________________________________________________________________SS#:________________________________________
Insurance Company Name & Phone:________________________________________________________________________________________________________
Insurance Company Address:________________________________________________________________________________________________________________
ID #:_______________________________________________________________________________________Group #:__________________________________________
Do You Have Secondary Insurance? _____ Yes _____ No
Policy Holder’s Name:____________________________________________________
Relationship To Patient:_________________________________________DOB:______________________________SS #:___________________________________
Insurance Company Name & Phone:________________________________________________________________________________________________________
ID #:____________________________________________________________________________Group #:_____________________________________________________
Is Your Case NF or WC? (Circle one)
Claim #:_______________________________________________________________________________________
MAX EFFORT PHYSICAL THERAPY
Name:_________________________________
Age:________
DOB:___________ Todays Date: ____________
Are You: ( ) Right Handed ( ) Left Handed
Employment:
_____ Full-time _____ Part-time
_____ Homemaker _____ Student
_____ Retired _____Unemployed
_____ Out of work due to injury
Occupation: ______________________________
Who referred you to Physical Therapy?
________________________________________________
________________________________________________
Home Environment:
_____ Alone _____ With Spouse _____ Other
Does your home have:
_____ Stairs, no railing _____ Stairs, w/ railing
_____ Ramps _____ Elevator _____ Uneven Terrain
_____ Other Obstacles: ______________________________
Do you use:
_____ Cane _____ Walker/Rollator _____ Wheelchair
_____ Other: ___________________________________________
Health Habits:
Do you exercises regularly? _____ Yes _____ No
If yes, how often and what type of activities?
____________________________________________________
Do you smoke? _____ Yes _____ No
If yes, how many packs per day? ______________
Alcohol use: __________ Daily __________ Weekly
Medical History:
Please Check if you have/had in the past
_____ Infectious Disease (such as tuberculosis,
hepatitis)
_____ Arthritis
_____ Blood Disorders
_____ Kidney Problems
_____ Broken Bones/ Fractures
_____ Low Blood Pressure/ Hypoglycemia
_____ Cancer
_____ Lung Problems
_____ Circulation/ Vascular Problems
_____ Multiple Sclerosis
_____Muscular Dystrophy
_____ Depression/Psychological Problems
_____ Osteoporosis
_____ Parkinson’s disease
_____ Repeated infections
_____ Diabetes/ High blood sugar
_____ Seizures/ Epilepsy
_____ Skin Disorder
_____ Eating or Nutritional Disorders
_____ Head Injury/ Concussion
_____ Strokes
_____ Heart Problems
_____ Thyroid Problems
_____ High Blood Pressure
_____ Ulcers/ Stomach Problems
_____ Sleep Disorders
_____ Weight Gain/ Loss
List Surgeries and Dates:
________________________________________________
________________________________________________
Medications:
Do you take any prescription medications?
_____ Yes _____ No
If yes, please list:
________________________________________________
________________________________________________
________________________________________________
Allergies:
Do you have any allergies? _____ Yes _____ No
If yes, please list:
________________________________________________
________________________________________________
History of Current Problem(s):
When did the problem(s) begin? _____/_____/_____
What happened?
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
Have you ever had this/these problem(s)
in the past? _____ Yes _____ No
If yes, when? _________________________________
What kind of treatment did you have?
________________________________________________
________________________________________________
________________________________________________
Did the problem(s) get better? _____ Yes _____ No
About how long did the problem(s) last?
_________________________________________________
_________________________________________________
_________________________________________________
How are you taking care of the problem(s) now?
________________________________________________
________________________________________________
What makes the problem(s) worse?
________________________________________________
________________________________________________
For Women:
Are you currently pregnant? _____ Yes _____ No
# of pregnancies: ________
Type of Delivery: ________________________________
Have you been diagnosed with pelvic
inflammatory disease? _____ Yes _____ No
Current Limitation(s): Check all that apply
_____ Difficulty w/ transfer from sit to stand
_____ Difficulty w/ squatting
_____ Difficulty w/ floor to/from stand transfer
_____ Difficulty walking:
_____ on level surface _____ on stairs
_____ on ramps _____ on uneven terrain
_____ Difficulty w/ self-care (such as bathing,
dressing, eating, toileting)
_____ Difficulty with home management (such as
household chores, shopping, driving or
transportation)
_____ Difficulty with carrying or lifting objects
_____ Difficulty with recreation/ play activity
History of Current Problem(s) Cont.:
What activities are you not able to do now that
you could do before the problem(s) began?
(Please be as specific as you can; for instance
“Unable to reach over my head”)
________________________________________________
________________________________________________
________________________________________________
________________________________________________
What are your goals for Physical Therapy?
________________________________________________
________________________________________________
________________________________________________
It is important that we have a measure of your pain. Please rate the level of your pain on the following
scale:
At present:
0
1
2
3
4
5
6
7
8
9
10
At best:
0
1
2
3
4
5
6
7
8
9
10
At worst:
0
1
no pain
2
3
4
5
moderate
6
7
8
9
10
extreme pain
Which of these words describe your pain? (Circle all that apply)
Sharp
Dull
Burning
Aching
Tingling
Numb
Constant
Variable
Please indicate painful areas by shading these models: