Physical therapy · KPM

Injury evaluation intake

This is a clinical intake, the same history I would take on paper at your first appointment. Filling it in now means your evaluation starts hands-on. It takes about five minutes and everything you share stays confidential.

1 · Submit this form
2 · I review your case
3 · We book your evaluation

Section 1 of 6 Patient details Basic details so I can reach you and put your case in context.

Full name * Age * Email * WhatsApp / phone *

Sex at birth

Relevant to some clinical reasoning. Skip it if you would rather not say.

Female Male Prefer not to say

Occupation * Hours seated per day

Repeated movements or sustained postures in a normal day The positions your body spends the most time in, and the movements it repeats most. This is often where the problem is built. Current activity level

Section 2 of 6 Your complaint Where it hurts and how it started.

Describe one injury only. Tell me about the injury you are dealing with now and the symptoms it causes: the one you want professional help to rehab. Old injuries and other conditions go in the history questions in section 4.

Main area of complaint *

Neck Shoulder Elbow Wrist / hand Upper back Mid back / ribs Lower back Hip / groin Thigh / hamstring Knee Shin / calf Ankle / foot Jaw / TMJ Other

Which side *

Left Right Both sides Central / midline

Any secondary areas that also bother you

How did it begin *

Sudden, specific incident Gradual, built up over time Woke up with it After surgery or procedure Not sure

How long has it been there * Since it started it has been *

What were you doing when it started * Has this happened before?

Section 3 of 6 How it behaves What it feels like and what changes it. This is where the movement shows itself.

Pain right now (0 to 10) At its worst, last 24 hours At its best, last 24 hours

What does it feel like *

Sharp Dull ache Burning Shooting Throbbing Stiffness Pins and needles Numbness Weakness Clicking or catching Giving way Swelling

Is it constant or does it come and go * Once aggravated, how long to settle

Pattern across the day

Worst in the morning Builds through the day Worst in the evening Worse at night in bed Wakes me from sleep Stiff after sitting still No clear pattern

Does it travel anywhere

No, it stays in one place Spreads locally around the area Travels down the arm Travels down the leg Travels past the elbow or knee

What makes it worse * What makes it better *

Section 4 of 6 Safety check and history If you tick anything in the first list, I will contact you before we book, and may ask you to see a doctor first.

Do any of these apply to you right now *

Unexplained weight loss in the last three months Fever, chills or night sweats Pain at night that wakes me and does not ease whatever position I am in Pain that is constant and does not change with movement or position Numbness around the groin or saddle area, or any change in bladder or bowel control Symptoms in both arms or both legs at the same time A recent fall, accident or collision A current or past cancer diagnosis A recent infection or illness Long-term steroid (corticosteroid) use Dizziness, visual disturbance or fainting when I move my neck None of the above

Existing medical conditions Current medications Previous surgeries or fractures Diagnosis or imaging results so far

Treatment tried so far, and whether it helped Attach any reports or scans (optional)PDF or image files, up to 5 files and 10 MB in total. You can also bring them to your first session.

Section 5 of 6 Goals and booking Sessions take place at My An Sport Center, Da Nang. Name up to three activities this problem makes difficult * What would a successful recovery look like for you * Preferred days and times

How would you prefer to pay *

Cash Card QR payment Invoice link SWIFT transfer Crypto (USDT / USDC) Not sure yet

Section 6 of 6 How you found me One quick question so I know where people hear about this work.

Where did you hear about me? *

Google search Google Maps Facebook Instagram TikTok YouTube Friend or family Another client Personal Trainer Danang No BS Academy app At My An Sport Center Airbnb Other

Who referred you? (optional, so I can thank them) If other, where?

Anything else I should know

ConsentPlease read and tick each box. All four are required before you send. The information in this form is accurate and complete to the best of my knowledge. I will tell Jeff about any change in my health, medications or symptoms before or during my sessions. I consent to Danang Physical Therapy collecting, storing and using the health information in this form, and any files I attach, to assess whether physiotherapy is suitable for me, plan my care and keep my clinical record, as described in the Privacy policy. I can withdraw this consent at any time. I have read and agree to the Terms of service. I understand that this form is not a diagnosis or an emergency service; that assessment and treatment can cause temporary soreness and carry a small risk of aggravating my symptoms; that no particular result is guaranteed; that Jeff may postpone treatment or refer me to a doctor if physiotherapy is not safe for me yet; and that I can ask questions, refuse or stop any part of treatment at any time. I am 18 or older, or my parent or legal guardian is completing this form with me and agrees to these terms.

I review every intake myself and reply on WhatsApp to book your evaluation. Not for emergencies: if you have severe or sudden symptoms, call 115.