Medical or Chiropractic Patient Form
Physical Therapy Only – TriCare
Weight Maintenance/Loss- New Patient Forms
When completing your forms we want to stress that DETAIL IS IMPORTANT!
Think about these questions as you fill out your forms:
1. WHEN did it begin? Insurance companies want the exact date of injuries, accidents or falls. For slowly developing problems think back, was it really weeks or has it been months. Is this the very first episode, or have you ever had something similar?
2. WHERE EXACTLY? Is the pain in the center? Worse on one side? Use the form to mark all trouble areas.
3. Is there a problem in only one specific place or does it radiate? Does it go up, into the head and cause headaches sometimes? Down? Into the leg, if so past the knee? Which fingers, which toes, what part of the foot or hand?
4. What does it feel like? Tight like a tight muscle? Sore? Sharp when you turn?
5. Grade the pain. Our 0-10 scale helps us understand what only you can feel. People regard their pain differently so here are some guidelines:
- 0 (zero) is NO pain,
- 3 – Pain would be present, but as you get busy you forget about it, but if you think about it, you notice it’s there.
- 5 – Can’t forget about it, but you are able to do you normal activities
- 8 – High degree of discomfort, must modify your activity due to the pain
- 10 – Is awful, horrible unbearable, normal activity impossible.
6. WHEN do you feel the pain? Is it worse in the morning, only present in the evening, does it keep you from sleeping? Everyday? Worse on workdays? Is it related to any specific activity or stress? What if anything makes it better or worse? (most of us are so busy trying to work around discomfort we have to think about this one in order to answer)
7. YOU ARE UNIQUE. Is there anything that the forms don’t tell us? It is not uncommon to find a 65-year-old grandmother is raising a 2-year-old and has to lift a 35-pound child 10 times a day. A truck driver may not just drive but also unload a full vehicle with a handtruck daily.
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