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Dreher Physical Therapy

Orthopedics, Geriatrics, Neurology and Rheumatology

www.timdreherpt.com

First & last name

Reason for care

When and how did the symptoms start

Pain/Quality of symptoms (check all that apply)

Achy

Dull

Stiff

Constant

Shooting

Burning

Numb

Tingling

Other

Other pain/quality of symptoms

What makes the symptoms worse

What makes the symptoms better

Does the problem radiate to other parts of your body

Any functional problems experienced on a daily basis (dressing, chores)

What were you able to do before this injury that you can’t do now

Where on your body are the areas of pain

Is this on the right or left side of your body

What is your pain level from 0-10 (0=none, 10=severe)? Please put 0 if you are in no pain.

Pain level at your best * Required

Pain level at your worst * Required

Pain level usually * Required

List any prior treatment and/or injections

Please list any falls, car accidents, fractures, sprains, strains

Did you receive an Xray, MRI, etc

What were the results of the test

Please bring in the written report of the tests, not the CD. Some of our computers can’t read the CD.

Please list all exercises, recreational activities and hobbies

GOALS:

What do you hope to achieve with care

REVIEW OF SYSTEMS: please check all of conditions that you have had or are currently experiencing.

Musculoskeletal

Joint Pain

Arthritis

Scoliosis

Osteoporosis

Cardiovascular

High Blood Pressure

Low Blood Pressure

Angina

Heart Attack

Stroke

Poor Circulation

Sensory

Blurred Vision

Ringing/Buzzing in Ears

Hearing Loss

Loss of Touch

Neurological

Headaches

Migraines

Anxiety

Depression

Sleep Problems

Vertigo/Dizziness

Respiratory

Asthma

Pneumonia

Emphysema

Sleep Apnea

Allergies

Endocrine

Immunue Disorders

Diabetes

Fatigue

Other conditions you have or are currently experiencing

List all surgeries

Please list any medications you are currently taking (you can bring a list to your first appointment)

Vitamins and supplements

Upload files

Select File

Upload prescriptions, test results, medications, and medical history documents

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