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Patient Health Information Form – Arcata

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  • Patient Health Information Form – Arcata
PRESENT SYMPTOMS
Have you had an XRAY, MRI, or other diagnostic procedure for this complaint?
Are the symptoms getting progressively worse?
Do the symptoms interfere with your occupation?
Do the symptoms interfere with your leisure?
Do the symptoms interfere with your sleep?
Please SHADE in areas on the Body Diagram where you feel pain.
Mark with an X areas where you have had broken bones :
Body Diagram
Please mark your pain level today:
No Pain Unbearable Pain
Pain Level: 0
How long in minutes can you perform the following activities without an increase in symptoms?
If applicable, do your symptoms affect your sexual activities?
Are you currently under the care of a physician for these symptoms?
Are you taking anti-depressants?
Please check any of the following conditions that you have, or have had in the past:
Musculo-Skeletal
Digestive
Nervous System
Circulatory/Respitory
Past Present
Past Present
Past Present
Past Present
Reproductive System
Skin
Other
Other
Past Present
Past Present
Past Present
Past Present
Please read the following and sign on the line for patient signature

I, , am here for physical therapy because I am ready to commit to my healing. I promise to make my wellness a priority in my life. I recognize that healing is a process and not an event, and that my therapist is here to help facilitate this process. I do not expect her to "fix" me.

I promise to show up for my therapy appointments on time, properly attired and ready to participate. I promise to do any "homework" I am given to the best of my ability. I promise to communicate openly and directly with my therapist and to ask questions when I do not understand information. I promise to share important information about my health with my therapist.

I understand that photographs may be taken as a visual aid both for myself and my therapist. I agree that the photos may be used for research purposes, with my identity concealed. These photos will be kept in my confidential medical file.

Patient's Signature: Date / /

I, Judi Nelson, promise to do my best to create a supportive, healing environment for our sessions. I promise to be present and listen to you. I promise to see you as a complex individual with your own healing process to go through at your own pace. I promise to respect your boundaries. I promise to continue learning and educating myself so as to provide you with up to date, quality care. I promise to work with you as a team to further your goals for health and well-being. I promise to respect and guard your privacy.

I PROMISE NOT TO TAKE YOUR POWER AWAY BY TELLING YOU I CAN "FIX" YOU. I PROMISE TO HELP YOU FIND AND NURTURE YOUR OWN INNER WISDOM AND INNATE HEALING CAPACITY.

Therapist's Signature: Date: / /