Pre-Evaluation Form:
In order to evaluate your condition fully, please be as accurate as possible. Thank you.
Are you an interviewer or a patient?
*
Interviewer
Patient
Staff Name
*
First Name
Last Name
Patient Name
*
First Name
Last Name
Are you working now?
Yes
No
If yes, what is the nature of your work?
E.g Prolonged sitting, repetitive lifting - expound as needed
1. Where is your pain/problem?
2. What caused your pain/problem?
3. Approximately when did it start?
4. List ONE ACTIVITY you are unable to do, that you absolutely want to be able to do again:
5. Have you ever had this same (or similar) pain/problem before?
Yes
No
(If yes, when and describe?)
6. In your understanding, what do you think will make it better?
7. How optimistic are you that you’ll get better?
Not at all
Mildly optimistic
Fair Very optimistic
Extremely
Date
*
-
Month
-
Day
Year
Date
Interviewer/Patient Signature (or Guardian)
*
Submit
p. 443.979.7171
AAA Physical Therapy, LLC
admin@AAAPhysicalTherapy.com
8975 Guilford Rd Ste 170 Columbia, MD 21046
f. 667.200.5908
Should be Empty: