Medical Intake Questionnaire

June 20, 2011

A medical intake questionnaire is designed to gather information that will make it possible to provide better health care or health based services to individuals. The questionnaire includes questions that seek to establish the person’s overall medical condition and this gives a better understanding of the person’s condition to the service provider. A clear medical record and account of any medical problems that exist is required. Other issues that are covered in a medical intake questionnaire include the type of medical tests that have been undergone as well as treatment for various medical conditions. The questionnaire is used to evaluate one’s state of health.

Sample Medical Intake Questionnaire

All the information contained in this questionnaire is strictly confidential.

Name…………………………………………………  Sex…………………………. Date of birth……………………………..

Address………………………………………………………………………………………………………………

City………………………………………….. State………………………..  Zip………………………………..

E-mail address……………………………………………………..

Mobile phone number…………………………………………

Telephone number………………………………………………..

Emergency contact number………………………………………………………………………….

Have you ever had physical therapy before? ……………Do you go for physical therapy regularly?  ……..

What kind of activities do you undertake on a daily basis?  ……………………………………..

Why do you need physical therapy? ………………………………………………………..

Have you tried any other form of treatment?  ……………………………………………………………..

Are there activities that induce pain? ……………………………………………………………………

How would you describe your sleeping patterns? …………………………………………………….

What level of physical therapy is suited to your condition? ………………………………………

a) Strenuous b) Moderate c) Light

Is any medical provider currently providing you with treatment? ……………………………….

What medication are you currently on? Please specify what it has been prescribed for……………………………

Have you undergone any surgical procedure? ………………………………………………………

Do you suffer from any chronic condition? If yes, please specify……………………………………

I have read and understood the information in this questionnaire. I am liable for any consequences resulting from the failure to release pertinent information pertaining to this questionnaire.

Date……………………………………………………………  Signature…………………………………………………

Download Medical Intake Questionnaire in Word Format

 

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