Get Form Pt Assessment Rev 3/03//17

Filling out the Form PT Assessment Rev 3/03//17 online can be straightforward and efficient with the right guidance. This document is designed to assist users in navigating through each section and field of the form easily.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to access the form and open it in your online editor.
2. Begin by entering the date of consultation in the designated field, followed by your name, date of birth, and social security number.
3. Select your sex by marking the appropriate checkbox for Male or Female.
4. Input your height and weight into the corresponding fields.
5. Indicate who referred you by filling in the 'Referred by' field.
6. Identify the leg where your complaints are located by checking the relevant box: Right, Left, or Both.
7. Describe your symptoms by checking all applicable boxes from the list provided.
8. Specify the location of your symptoms by marking one of the options provided.
9. Rate the severity of your symptoms by selecting the option that best describes your experience.
10. Note how long your symptoms have been an issue in the respective fields.
11. Answer the question about ulcers by checking 'Yes' or 'No' and provide additional details if applicable.
12. Explain when your symptoms occur by selecting the option that applies most closely to your experience.
13. Indicate if your symptoms are worse in one leg by checking the appropriate box.
14. Answer the question regarding the impact of your symptoms on your activities of daily living and specify the affected activities if applicable.
15. List any factors that worsen your symptoms by checking all relevant boxes.
16. Mark any conservative therapy measures you have tried to alleviate your symptoms.
17. Provide information about any vein treatments you have undergone in the past.
18. Check any relevant items from your past medical and surgical history.
19. Disclose any allergies you may have and provide a list of medications you are currently taking.
20. Finally, review all your responses for accuracy before saving your changes, downloading, printing, or sharing the completed form.

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