Annual PT Exam Form

Full Name(Required)

Last Name(Required)

Date(Required)

Gender(Required)

Male

Female

Occupation(Required)

Your Medical and Surgical History-Please Check all the apply(Required)

Please Give Details for any Checked Items(Required)

Specifically for Men

History of prostate disease

Medical History -Specifically for Women

History of endometriosis

Menstrual cycle (including perimenopausal or menopausal)

Pelvic disorders

Pregnancies and pregnancy-related pain

Vaginal and caesarian deliveries

Please List all Prescription Medications(Required)

How many days a week are you physically active to a moderate or vigorous degree?(Required)

How Many Minutes Per Day are You Physically Active?(Required)

What Activities/Exercises are You Involved With?(Required)

List Any Activities You Have Difficulty Participating In(Required)

List any Areas of Pain, Lack of Movement or Weakness in Your Body:(Required)

If You Completed an Annual PT Exam Last Year, Do You Have Any New Health Concerns in the Past 12 Months? Please List:(Required)

Date of Scheduled Exam(Required)

Time of Scheduled Exam(Required)

Phone Number(Required)

Annual Physical Therapy Exam Pre-Exam Form