Fillable INITIAL EVALUATION SUBJECTIVE REPORT

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INITIAL EVALUATION SUBJECTIVE REPORT

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INITIAL EVALUATION SUBJECTIVE REPORT
Name _____________________________________________________ Date ___________________________________
How do you prefer to be addressed? ____________________________ Age ____________________________________
Occupation ________________________________________________ Height ________________ Weight ___________
Address ___________________________________________________________________________________________
Phone/Fax _________________________________________________ E-Mail Address: __________________________
How did you hear about us? ___________________________________________________________________________
Referring Physician __________________________________________________________________________________
Address ____________________________________________________________________________
Phone/Fax __________________________________________________________________________
Referring Therapist __________________________________________________________________________________
Address ____________________________________________________________________________
Phone/Fax __________________________________________________________________________
The following is very important to our evaluation process.
Please ll out these forms as specically as possible to provide us
with a clear picture of your present symptoms, abilities, and goals.
1. What is the primary complaint that brings you here to Therapy on the Rocks?
Please describe your symptoms as specically as possible.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
2. Secondary complaint? ____________________________________________________________________________
__________________________________________________________________________________________________
3. On what date did your symptoms begin? ____________________________________________________________
Therapy On The Rocks
676 N State Route 89A
Sedona AZ 86336
928-282-3002
www.therapyontherocks.net
4. How did your symptoms begin?
For example, did your symptoms begin as a result of an accident or trauma, or did they begin without a known reason?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
5. Have you ever received the following treatment for this condition?
If yes, please indicate length of treatment and effectiveness.
Physical Therapy _____________________________________________________________________
MFR _______________________________________________________________________________
6. Put a slash mark on the line below to indicate the INTENSITY of your symptoms:
None _____________________________________________________________ Worst Possible
7. Put 2 slash marks on the line below to indicate the BEST and WORST your symptoms have been in the past week:
None _____________________________________________________________ Worst Possible
8. Put a slash mark on the line below to indicate the FREQUENCY of your symptoms:
Never ____________________________________________________________ Constant
9. What activities increase your pain?
10. What activities decrease your pain?
11. On the lines below, place a slash mark to indicate your daily functional ability as a percentage of normal:
On a “good day” 0% _______________________________________________ 100%
On a “bad day” 0% _______________________________________________ 100%
12. For each activity listed below, please note the amount of time in minutes or hours that you can perform before you feel
that you need to stop because of your symptoms. If you have no difculty with the activity, mark OK; if you are unable
to perform the activity, mark UNABLE; if this does not apply to you, mark NA.
Activity Tolerance Activity Tolerance
Sitting Computer Work
Standing Exercise
Walking Writing
Stairs (# of stairs/ights) Shopping
Driving Bending
Sleeping Reaching (# of repetitions)
Lifting (# of pounds) Carrying (# of pounds)
Other Other
Other Other
13. What are your goals for this treatment program? For example, what activities from the above list would you like to
be able to perform better or longer? How long in minutes or hours do you need or want to perform each activity?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
14. Do you have any of the following medical conditions?
Yes No Yes No
Circulatory problems Blackouts
High blood pressure Visual disturbances
Heart trouble Weight changes (>15lbs)
Pacemaker Headaches
Epilepsy Ringing in the ears
Diabetes Bowel/bladder problems
Pregnancy Malignancy
Stroke Other
15. Past Medical History: Please list any surgeries, traumas, accidents or other conditions and the dates of occurrence.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
16. Please place a check in front of each item that you experience at least monthly. Place an X in front of each item that
you experience weekly or more frequently.
_______Headache
_______Heart pounding or racing
_______Irregular heartbeat
_______Chest pain, tightness
_______Numbness, tingling in arm or leg
_______Can’t keep warm enough
_______Sweaty palms
_______Blushing, ushing face
_______Coughing
_______Stuffy nose, congestion
_______Earache or ringing noise in ears
_______Common colds
_______Sore throat
_______Asthma or shortness of breath
_______Hay fever or allergies
_______Sore, aching muscles
_______Stiff or tender joints
_______Back problems
_______Trembling/twitching muscles
_______Skin rashes, eruptions
_______Grinding of teeth (TMJ)
_______Dry mouth
_______Mouth sores
_______Excessive perspiration
_______Difculty sleeping through the night
_______Excessive drowsiness during the day
_______Periods of extreme fatigue
_______Feeling faint or dizzy
_______Feeling tense or nervous
_______Difculties with family or friends
_______Worrisome thoughts
_______Recurring bad thoughts
_______Thoughts of suicide
_______Fearful of persons or places
_______Feeling inadequate/unable to cope
_______Feeling guilty or failure
_______Uncontrolled crying or sadness
_______Easily annoyed or irritated
_______Free-oating anxiety about life
_______Voice quivering, shaking
_______Eyes irritated or inamed
_______Vision blurred
_______Eyestrain or discomfort
_______Nosebleeds
_______Stomach cramps
_______Heartburn or indigestion
_______Nausea or vomiting
_______Frequent urination
_______Incomplete urination
_______Painful urination
_______Urinary leakage
_______Bowel leakage
_______Gas in lower bowel
_______Diarrhea
_______Constipation
_______Bowel irregularity
_______Uninterested in sexual relations
_______Unable to participate in sex acts
_______Menstrual difculties
_______Breast tenderness
_______Hot ashes
_______Water retention
_______Over-eating, bingeing
_______Lack of appetite
_______Excessive alcohol abuse
_______Other substance abuse
_______Frequent laxative use
_______Other:
17. MEDICATIONS Please indicate below ALL medications which you are currently taking, the problem for which
you are using them, the dosages, and their effectiveness
Medication For Treatment of Dose/Amt/Day Effectiveness
18. Please shade area(s) of pain and/or symptoms.
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INITIAL EVALUATION SUBJECTIVE REPORT

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Completed 15 October 2021

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