Name:
THIS SPACE IS FOR OFFICE USE ONLY
Date:
Cardenas & Associates Physical Therapy
5359 Balboa Blvd., Unit A
Encino, California 91316
Phone: (818) 506-7821
Fax: (818) 506-6722
The following information will help guide your physical therapist’s evaluation of your problem.
Use the following symbols to mark the location(s) of your symptoms (pain, numbness, etc.) on the body chart to the right:
Pain = PPPP
Numbness = NNNN
Tingling = TTTT
Burning = BBBB
Swelling = SSSS
Rate your Pain Intensity. Circle one number to indicate how much pain you have at best and one number to indicate how much pain you have at worst.
012345678910
Please respond to all the items below related to your general health.
Acid Reflux
CurrentlyIn the pastNever
Anxiety Problems
Alcohol Abuse
Asthma
Cancer
Chronic Fatigue Syndrome
Congestive Heart Failure
Diabetes
Depression
Fever
Fibromyalgia
Fracture
Heart Attack
Heat Sensitivity
High Blood Pressure
High Cholesterol
Incontinence
Infection
Irregular Heartbeat
Metal Implants
Osteoporosis
Recreational Drug Use
Seizures
Sexual Dysfunction
Smoking
Stroke
Thyroid Problems
Ulcers
Have you undergone any surgeries?
NoYes
Please list:
Are you taking any medications?
Are you taking any vitamins or herbal supplements?
PATIENT or GUARDIAN SIGNATURE:
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