We help people aged 50+ keep active and free of pain meds
even if their doctors and kids are telling them to "just take it easy."
Call Dr. Berman Today! (239)564-0069

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We help people aged 50+ keep active and free of pain meds even if their doctors and kids are telling them to "just take it easy."

We help people aged 50+ keep active and free of pain meds even if their doctors and kids are telling them to "just take it easy."

Patient Questionnaire
This information is kept confidential

client information 06-24-17

Your IP Address 54.92.133.186

emergency contact
Present Condition

What are the current symptoms of the problem(s) for which you are seeking treatment?

Select the value that best describes your pain levels in each case. 1 = No Pain 10 = High Pain

What makes your symptoms worse?

What makes your symptoms better?

Are you currently taking any medication for your symptoms? What? How much?

What does this pain keep you from doing?

What do you think initially caused your symptoms? When?

Current history of complaint
medical history

Please list all medical conditions and/or health concerns including history of cancer, seizures, night sweats, unexplained weight loss, strokes.

Please list all current medications.

Please list all previous surgeries and dates.

optional request

How did you hear about us?

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By signing digitally I agree to the terms viewable by clicking here.

I understand that Medicare will not reimburse for services rendered by Berman Physical Therapy, LLC.

Upon successful submission, the application will be securely sent to Dr. Berman and a full copy will be sent to the email address provided. No other copies of this information will exist, nor will it be shared beyond the disclosure posted. Our webmaster does not collect, copy or transfer the information in this form.