Montana Myofascial Release Treatment Centers
Back In Motion Eastside PT & Body Restoration
612 1st Avenue South, Great Falls, MT 59401 101A Main Street, Stevensville, MT 59870
406-750-2655 Phone 406-777-2679 Fax (406)777-2676
Back In Motion Integrative Therapy
New Patient Information Sheet
Welcome to our practice!
Please help us serve you better by taking a few minutes to provide the following information.
Name:_______________________________________________________________________ Today's Date:________________________________
Last name First Name
Street Apt# City State Zip
Phone Number: Cell (______)____________________ Home (______)____________________ Work (______)____________________
Date of Birth:__________________ Age:____________________ Gender: M F
Occupation:_______________________________________________ Employer:__________________________ Marital Status: M S W D
Emergency Contact: Name:______________________________ Phone: (______)____________________
Primary Care Physician:____________________________________ Date of next visit: _________________
Specialist Physician: _______________________________________ Date of next visit: _________________
How did you hear about our practice? ____________________________________________________________
Did anyone refer you? __________ Name: __________________________________________________________
The following is very important in our evaluation process.
Please fill out these forms as specifically as possible to provide us with a clear picture of your
present pain and functional status.
What is the primary complaint that brings you in today?
As a result, I am now having difficulty with:
Are you currently experiencing pain as a result of these symptoms? Yes No
When did your symptom(s) begin? Date: ____________________
Please rate the Intensity and Frequency of your pain with "0" being no pain, "5" being moderate pain, and "10" being unbearable pain.
Your Pain Intensity Rating: ______________________________ Your Pain Frequency Rating: ______________________________
More specifically, rate your pain using the At its worst ____________________
same "0" to "10" scale. At its best ____________________
At present ____________________
Night (sleeping) ____________________
At what time of day are your symptoms the worst? ________________________________________________________________
At what time of day are your symptoms the best? _________________________________________________________________
What activities increase your pain? _______________________________________________________________________________
What activities decrease your pain? _______________________________________________________________________________
What other types of treatment have you had for this problem?
_____Massage _____Bodywork _____Physical Therapy _____Myofascial Release _____Chiropractic
_____Surgery _____Other Medical Treatment: (Please Describe) ________________________________________________
Check the box if you have had any of the following medical conditions?
__________ Diabetes __________ Varicose veins __________ Neurological problems
__________ Rheumatic fever __________ Circulatory problems __________ Stroke
__________ Heart Murmur __________ Lung disease __________ Broken bones (fracture)
__________ High blood pressure __________ Epilepsy/seizures __________ Kidney disease
__________ Heart disease/pacemaker __________ Malignancy __________ Liver disease
__________ Migraine headaches __________ Arthritis __________ Metal implants
__________ Osteoporosis __________ Pregnancy __________ Blackouts
__________ Weight change __________ Other: explain_______________________________________________
List past medical history and dates of occurrence. Include surgeries, accidents and other traumas.
List ALL medications which you are currently taking, the condition for which you are using them, the dose, and their effectiveness. (Include Supplements, herbal and homeopathic remedies).
Medication for treatment of Dose/Amt. per day Effectiveness
Do you have any skin or medication allergies? Yes __________ No __________
If so, which? ____________________________________________________________________________________________________________
Is there a chance you may be pregnant at this time? Yes __________ No __________
Do you engage in regular exercise? Yes __________ No __________
What type and how often? __________________________________________________________________________________________________________________
are you able to exercise now? Yes __________ No __________
Do you have discomfort, shortness of breath, or pain with exercise? Yes __________ No __________
Please describe ___________________________________________________________________________________
In general, your lifestyle is: 1 2 3 4 5
Active Average Inactive
If sleep is a problem, answer these questions:
Do you have trouble falling asleep? Yes __________ No __________
Is your sleep restful? Yes __________ No __________
Do you find it difficult to lie down? Yes __________ No __________
Do you find it difficult to change positions in bed? Yes __________ No __________
How many times do you wake in the night? _____________________________
How long before you fall back to sleep? ___________________________________________
List all the TASK/ACTIVITIES that you have difficulty performing and your tolerance (minutes/hours) for each task/activity. If you are no longer able to perform an activity, your tolerance would be "0".
Task/Activity Tolerance (minutes/hours)
1.__________________________________________ 1. _________________________________________
2. _________________________________________ 2. _________________________________________
3. _________________________________________ 3. _________________________________________
List the activities that you would like to be able to do as a result of therapy.
Activity Duration/How Often By When
1. _____________________________________________ _______________________________ ____________________________
2. _____________________________________________ _______________________________ ____________________________
3. _____________________________________________ _______________________________ ____________________________
Other Goals? ____________________________________________________________________________________________________________
I understand that Back In Motion Integrative Therapy, may use or disclose my personal health information for the purpose of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment.
Photographs taken during initial evaluation, progress evaluation and discharge summary will be used for postural comparison purposes and as educational tools. By signing below you consent to the use of these photographs in a professional manner.
I do hereby agree and give my consent for Back in Motion Integrative Therapy, to furnish care and treatment which is considered necessary and proper in the diagnosing or treatment of my physical conditions.
I understand that I retain the right to revoke this consent by notifying the practice in writing at any time.
I hereby certify that all the above information is true to the best of my knowledge.
Patient/Parent/Guardian Signature: ___________________________________________________ Date:________________________