Microsoft word - 22-meeks+pre+assessment

Name:____________________________________ Age____ Date of Birth: _____________ Address:___________________________________________________________________ Phone: _________________________(H)____ (W)____ (C)____ Email address:______________________________________________________________ Referred by:________________________________________________________________ Please CHECK any of the following that apply to you:
Other Ethnicity__________ Over- Exerciser Family History Osteoporosis Postural Changes Do you smoke? Yes___ No___ If yes, how many packs do you smoke per day?____ How long____ Do you drink alcohol? Yes____ No____ If yes, how many drinks per day?____, per week?______ ***********************************************************************
Please CHECK any of the following conditions you either have or have had previously.
Other_____________________________________ ****************************************
Are you taking, or have you taken, any of the following medications?
Selective Serotonin Reuptake Inhibitors Selective Serotonin Reuptake Inhibitors (Prozac, Zoloft, Levapro) Other_______________ ****************************************
Regarding broken bones please CHECK any that apply to you (list date of fracture)
Wrist Fracture Spinal Compression Fracture ****************************************
Please provide the following information—Use extra sheet if necessary
1) Have you had a bone density test in the last 2 years? Yes____ No____ If Yes, please bring your test with you or have your physician send us a copy. 2) Have you fallen within the past 3 months? Yes____ No____ If Yes, please explain _____________________________________________________________________ 3) Do you get dizzy or lightheaded? Yes____ No____ If Yes, please explain _____________________________________________________________________ 4) Are you up and on your feet at least four hours per day? Yes____ No ____ 5) How many hours do you spend sitting in a day Reading______ Watching TV______ Playing Cards ______ Doing Needlework______ Computer______ Other______ 6) Do you have any difficulty with everyday activities such as: getting in/out of bed, standing up from a chair, dressing, brushing teeth or hair? Yes____No____ If yes, please explain._________________________________________________________ 7) Have you noticed increased pain in any body part? Yes___ No____ If yes, please describe______________________________________________________________ 9) What is your major concern about your condition? 10) Are you currently under a physician’s care for any other condition? Please explain 11) Is there anything else you would like to tell me that you think would help me treat you? Please feel free to bring any other information with you on your first visit. I’m looking forward to meeting you.


Docteur monique clouzeau

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