Home→Resources→Forms→Patient QuestionnairePatient questionnairePlease complete the following form prior to attending your first scheduled appointment. Patient Questionnaire Name(Required) First Last Phone(Required)List the location(s) of your symptoms.(Required) Add RemoveDescribe relevant symptoms (i.e. sharp, dull, stabbing, etc.).(Required) Describe HOW and WHEN your problem(s) developed.(Required)Rate the intensity of your discomfort on a scale of 1 to 10 (10 being the worst).(Required)Please enter a number from 1 to 10.How would you describe your pain?(Required) Constant Periodic Occasional What positions or activities make your symptoms WORSE?(Required) What positions or activities make your symptoms BETTER?(Required) List significant past and current medical conditions (i.e. heart disease, cancer, pregnancy, pacemaker, spinal implants, etc).(Required) Add RemoveList any goals you would like to achieve with Physical Therapy treatment.(Required) Add RemoveHave you received any PHYSICAL THERAPY TREATMENTS in this calendar year (JAN-DEC)? Or, have you received any other treatments for this condition? Please describe.(Required)List medications you are currently taking for this problem.(Required) Add RemoveList any special test, such as Xrays, MRI, EMG, that you have had in regards to your current problem.(Required) Add RemoveIs this work related as a worker's compensation claim?(Required) Yes No Do you need to pre-certify for physical therapy services under your health care plan?(Required) Yes No Are treatments provided by Floyd County Medical Center covered by your insurance?(Required) Yes No I don't know
