Clinical Intake Form for Anatomia Physical Medicine
Required Field
Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Gender
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Occupation
Contact Info
Mobile Phone
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Source of Referral
Address
City
Country
Australia
Canada
Ireland
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Bouvet Island
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Chile
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Cook Islands
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Heard Island And Mcdonald Islands
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Isle Of Man
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Korea, Republic Of
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Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
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Lithuania
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Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
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Northern Mariana Islands
Norway
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Palestinian Territory, Occupied
Panama
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Paraguay
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Pitcairn
Poland
Portugal
Puerto Rico
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Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Other
Medical Info
Primary Complaint
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General Health
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Current Treatment
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Past Treatment (from other practitioners)
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Medications
Injuries
Surgeries
Additional Info
Conditions
Health Questions
Meniere Disease
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Vertigo
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Asthma
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Epilepsy
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Migraines/Headaches
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Warts
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Blood thinner medication
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Gastrointestinal
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Mood Disorder
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Cancer
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Hearing Impairment
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Pacemaker
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Cardiovascular
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Heart Attack
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Past Heart Surgery
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Concussion
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Heart Condition
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Schizophrenia
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Congenital Heart Defect
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High blood pressure
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Stroke
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Depression
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HIV/Aids
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Low blood pressure
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Varicose veins
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Diabetes
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TMJ (Jaw)
Clenching
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Grinding
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Clicking
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Jaw Pain
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Difficulty Chewing
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Locking
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Difficulty Opening Jaw
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Morning Stiffness
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Ear Blockage
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Ear Pressure
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Ear Ringing
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Ear Stuffiness
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Treatment Goals
Improve Well Being
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Pain Relief
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Rehabilitation
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Stress Relief
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Support in Healing/Recovery
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Improve Lifestyle
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Improve Symptoms
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Other
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Feet
Mallet Toe
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Plantar Fasciitis
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Claw Toe
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Onychauxis
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Plantar Wart
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Corns/Callouses
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Dry/Cracked Skin
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Onychocryptosis (Ingrown Nail)
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Previous Amputations
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Hallux Valgus
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Onychomycosis (Nail Fungus)
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Thickened Nails
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Hammer Toe
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Onychoptosis (Nail Loss)
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Yellow Nails
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Heel Fissures
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Overlapping Toes
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Involuted Nails (Curved/Pinched)
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Pes Cavus (High Arch)
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Itchy or Peeling Skin
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Pes Planus (Flat Feet)
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Bunions
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Energy
How long do you sleep on average?
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Is your energy constant?
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What is your energy level upon awakening?
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When is your energy highest?
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When is your energy lowest?
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Do you struggle with insomnia?
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Does your energy fluctuate?
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Emotion / Memory
Alzheimer Disease
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Anxiety Disorder
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Mood Disorder
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Schizophrenia
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Stress
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Substance Use Disorder
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Well Being
Mobility/Walking Aids
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Range of Motion
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Smoking
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Caffeine
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Drinking
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Exercise
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Flexibility
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Energy Level
Dull
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Even
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Fatigue
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Flat
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High
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Agitated
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Low
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Chaotic
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Vibrant
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Clear
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Infectious
Epstein Barr
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Lyme Disease
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Pneumonia
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Strep
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Female Health
Hysterectomy
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Menopause
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Breast Cancer
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Currently Pregnant
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COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Willing to wash hands before entering clinic
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Willing to wash hands before leaving clinic
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Willing to wear face mask in the clinic
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Agree to wear face mask during treatment
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Have you taken precautions to limit exposure
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Have you been tested for COVID?
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Have you had the antibody test?
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Fever Over 100.4 degrees
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Fever Over 38 degrees
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Headaches
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What is your Temperature?
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New Onset of Cough
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Worsening Chronic Cough
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Sore Throat
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Difficulty Swallowing
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Shortness of Breath
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Difficulty Breathing
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Persistent Pain in Chest
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Decrease or sudden loss of taste and smell
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Have you had a new onset of muscle aches and pain since the emergence of the virus?
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Unexplained Fatigue/Malaise/Muscle Aches (Myalgia)
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Fatigue
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Chills
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Pink eye (conjunctivitis)
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Nasal or sinus congestion
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Runny nose/nasal congestion without other known cause
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Nausea
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Vomiting
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Diarrhea
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Abdominal Pain
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Sudden onset body aches
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New rash or other skin changes
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Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin?
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Regular cardio exercise
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Can you exercise to get your heart rate up without any problem?
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Can you exercise to get your respiratory rate up without any problem?
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Contact with someone with COVID
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Had close contact with a confirmed case of COVID-19 without wearing PPE
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Contact with someone who is awaiting COVID test results.
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Contact with someone who was in contact with COVID
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Contact with anyone with acute respiratory Illness
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Recent domestic air travel
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Recent international air travel
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Recent travel to area with high infection rates
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Recent travel outside your province within the past 14 days
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Did you travel outside of Canada in the past 14 days?
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Been in group where social distancing not observed
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Are you considered high risk?
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Spend time around anyone that is high risk
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If over 70, unexplained or increase number of falls?
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If over 70, acute functional decline?
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If over 70, worsening of chronic conditions?
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If over 70, symptoms of delirium?
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No COVID Symptoms
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Oncology
Cancer Type
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Date of Diagnosis
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Location
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Status
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Lymph Nodes Removed
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Other Treatments
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Excessively Warm/Cold
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Yoga
Have Practiced Yoga
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Date of Last Yoga Class
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How Often?
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Area of Complaint
Neck
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Left Side of Upper Back
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Right Side of Upper Back
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Mid Back
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Left Side of Mid Back
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Right Side of Mid Back
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Low Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Left Thigh
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Left Calf
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Right Leg
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Right Thigh
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Right Calf
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Left Gluteal
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Right Gluteal
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Left Hip
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Right Hip
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Left Groin
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Right Groin
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Sacrum
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Tailbone (coccyx)
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Headaches
Chronic Daily Headache
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Cluster
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Headaches
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Migraines
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Rebound
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Sinus
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Tension
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Other Headaches
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Musculoskeletal
Baker's Cyst
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Spasms / Cramps
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Degenerative Disk Disease
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Jaw Pain (TMJD)
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Osteoporosis
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Bone Disease
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Spondylolisthesis
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Dislocation
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Joint Injury
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Paget Disease
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Bone or Joint Disease
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Strain/Sprain
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Dupuytren's Contracture
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Joint Stiffness / Swelling
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Plantar Fasciitis
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Psoriatic Arthritis
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Broken Bone / Fracture
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Temporomandibular Joint Dysfunction
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Ehlers-Danlos Syndrome
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Muscular Dystrophy
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Adhesive Capsulitis
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Recti Diastasis
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Carpal Tunnel Syndrome
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Tendonitis/Bursitis
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Fibromyalgia
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Myasthenia Gravis
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Amyotrophic Lateral Sclerosis (ALS)
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Scleroderma
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Chronic Fatigue Syndrome
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Torticollis
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Fracture
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Osgood-Schlatter Disease
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Ankylosing Spondylitis
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Scoliosis
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Chronic Myofascial Pain Syndrome
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Whiplash
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Gout
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Osteoarthritis
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Arthritis
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Artificial Joints / Special Equipment
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Sinus Problems
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Compartment Syndrome
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Hereditary/Congenital Deformity
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Osteomalacia
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Other Musculoskeletal
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Gastrointestinal
Eating Disorder
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Digestive Conditions
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Diverticulitis
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Other Gastrointestinal
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Skin
Herpes
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Hypersensitive Reaction
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Hypersensitive Reactions
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Infectious Skin Conditions
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Melanoma/Carcinoma
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Athletes Foot
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Non-Surgical Scars
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Bruise Easily
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Plantar's Wart
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Eczema
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Skin Conditions
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Other Skin
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Blood
Blood Thinner Medication
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Hepatitis
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HIV
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HIV/AIDS
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Other Blood
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Immune
HIV/Aids
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Rheumatoid Arthritis
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Allergies
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Anaphylaxis
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Other Immune
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Neurological
Parkinsons
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Bell's Palsy
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Peripheral Neuropathy
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Brain Injury
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Sciatic Pain
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Carpal Tunnel
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Seizure Disorder
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Chronic Pain Disorder
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Shingles / Herpes
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Fibromyalgia
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Stroke
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Multiple Sclerosis
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Tingling
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Transient Ischemic Attacks (TIA)
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Numbness
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Other Neurological
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Cardiovascular
Low Blood Pressure
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Raynaud Disease
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Angina
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Cardiovascular Accident
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High Blood Pressure
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Other Cardiovascular
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Respiratory
Infectious Respiratory Conditions
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Tuberculosis
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Other Respiratory
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Endocrine
Adrenal Fatigue
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Diabetes
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Other Endocrine
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Hearing
Ear Problems
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Tinnitus
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Other Hearing
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General Injury Related Questions
What is the next competition/challenge?
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Previous sports-related injuries?
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Treatment of previous injury?
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Physical Therapy
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Chiropractic
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OTC medications
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Pain medications or steroids
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Surgery (type/year)
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Complications from that injury?
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Reproductive
Other Reproductive
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Miscellaneous
Visually Impaired
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Autism
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Contact Lens
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Dentures
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Hearing Impaired
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Mental Health Issues
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Surgical Pins or Wire
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Vision Problems
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Other Medical Conditions
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Other Diagnosed Diseases
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Eating Habits
Breakfast
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Lunch
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Dinner
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Snacks
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Massage Goals
Balance
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Flexibility
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