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Campus Physical Therapy Practice Manager
Patient Information (for office use only)
 Patient ID Date of Survey
Patient Name Gender Date of Birth
Clinician Name Body Region Patient Name
Impairment CareType Payor Source

Welcome

FOTO Patient Intake Survey

Arm/Hand

Foto Patient Intake Survey

The following assessment will ask you about difficulties you may have with certain activities. It is important part of your evaluation. It will help us: understand how your condition is affecteing your activities, and develop treatment goals for you.

Please answer the questions with respect to the problem for which we are seeing you. Respond bsed on how you have been over the past few days.

Today, using your affected arm, are you able to ?
 unable to do with severe difficulties with moderate difficulties with mild difficulties with no difficulties
1.
put on your pullover sweater?
2.
turn a key ?
3.
carry a small suitcase?
4.
wash your back?
5.
carry a shopping bag or briefcase?
6.
do heavy household chore (washing windows or floors?
7.
luander chothes (e.g.wash, iron, fold?
8.
do up buttons?
9.
open a tight or new jar?
10.
open doors?
11.
Rate the level of pain you have had in the last 24 hours?
 1 2 3 4 5 6 7 8 9 10
12.
indicate the number of surgeries four your primary condition?
 None 1 2 3 >4
13.
How many days ago did the condition begin?
 0-7 days 8-14 days 15-21 days 22-90 days 91 days to 6 months >6 months
14.
Are you taking prescription medication for this condition?
 Yes No
15.
Have you received treatment for this condition?
 Yes No
13.
How often have you completed at least 20 minutes of exercises, such as jogging, cycling, or brisk walking , prior to the onset of your condition?
at least 3x per week at 1x or 2x per week at seldom or never

Other health conditions may affect your treatment. Please check any of the following that apply to you.

17.
Musculoskeletal
 Arthritis Osteoporosis Back Pain Previous Accidents Prior Surgeries
17.
Cardiovascular
 Congestive Heart Failure High Blood Pressure Heart Attack Peripheral Vascular Disease Pacemaker Angina
17.
Neurological
 Headaches Neurological Disease Seizures Stroke or TIA Sleep Dysfunction
17.
Senses
 Visual Impairment Hearing Impairment
17.
Psychological
 Anxiety or Panic Disorders Depression Other Disorders
17.
Hematopoietic
 Hepatitis, HIV AIDS Cancer
17.
Pulmonary
 COPD/ARDS Tuberculosis Asthma
17.
Endocrine
 Diabetes Types I II
17.
Gastrointestinal
 Gastrointestinal Disease
17.
Genito Urinary
 Kidney Bladder Prostate Urinary
18.
Height and Weight?
 Height (ft-in) Weight (lbs)