Pre-Session Form

Name *

First

Last

Email *

Email

Confirm Email

Date of Birth (Month, Day, Year) *

Age *

Home Phone Number *

Cell Phone Number *

Work Phone Number *

Home Address (City, State, Zip) *

Employer Name & Address (City, State, Zip) *

Emergency Contact (Name, Phone, Address) *

Your Goals For Physical Therapy *

What Are Your Athletic Goals? *

How did you hear about BodMechanic? *

Type of Injury/Condition *

Onset/Injury Date (Approximate Month, Day, Year) *

Physical limitations due to injury *

What activities aggravate your symptoms? *

Type of Surgery (If Applicable)

Surgery Date (If Applicable)

Month, Day, Year

Describe any previous treatment for this condition *

Have you had any diagnostic tests for this condition? If so, what? *

Please describe your pain: *

Please rate your current pain

Pain Level: 1

1 = Good | 10 = Bad

Please rate your pain at its worst

Pain Level: 1

1 = Good | 10 = Bad

Please rate your pain at its best

Pain Level: 1

1 = Good | 10 = Bad

Please let us know the location of your symptoms (Front) *

Please let us know the location of your symptoms (Back) *

Are you currently taking medications? *

Yes
No

Please list meds: *

Have you recently noted any of the following? (Check all that apply) *

Pain at Night
Dizziness or Nausea
Burred Vision, Sensitivity to Light
Not Applicable

Do you have now or have you ever had any of the following? (Check all that apply) *

Sprains/Strains
Concussions or Head Traumas
Eye Surgery
Not Applicable

Any previous injury that may affect current care? Please describe: *

Please explain & give approximate dates for any conditions marked above: *

NIJMEGEN QUESTIONNAIRE (Last Questions!)

Please select the number below that best represents what you have felt recently.

0 = Never | 1 = Rare | 2 = Sometimes | 3 = Often | 4 = Very Often

Chest Pain *

Feeling Tense *

Blurred Vision *

Dizzy Spells *

Feeling Confused *

Faster or Deeper Breathing *

Short of Breath *

Tight Feelings in the Chest *

Bloated Feeling in the Stomach *

Tingling Fingers *

Unable to Breathe Deeply *

Stiff Fingers or Arms *

Tight Feelings Round Mouth *

Cold Hands *

Palpitations *

Feeling of Anxiety *

If there is any additional information you would like us to know, please write it here.

I agree to the conditions and information stated in this form and consent for physical therapy. *

I Agree

Please fill out all sections below.

NIJMEGEN QUESTIONNAIRE (Last Questions!)

Subscribe to our free newsletter