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Sample Intake Examination for Therapeutic Exercise

George lives with his elderly parents and is their caregiver. He has a brother that lives in another city but rarely visits the family. He has never been married. His cultural background is Italian. He loves eating rich Italian foods.

George is currently employed as a special education teacher at a local middle school. His recreational activity is watching movies at home or in the local theater.

Growth and Development:
George is right hand and foot dominant.

Living Environment
George lives with his elderly parents. George drives a car and has no limitations for community accessibility.

General Health Status Habits and Behaviors/Past/Present:
George’s range of motion is also inhibited by his sedentary lifestyle.

Medical Surgeries/Psychological History/Medication: Current/Past:
George has no history of any major surgeries. He has never sought psychological treatment or take prescribed medication. George admit to taking Advil, Tylenol, and Naproxen all over the counter drugs to ease his pain.

Family History:
George has a family has a history of high blood pressure, heart attacks, and type 2 diabetes, putting him at risk. Other family illnesses are obesity, atrial fibrillation, and gout.

Cognitive Social/Emotional Status:
George does not have any orientation or memory issues. His communication skills are age-appropriate for a university graduate and teacher. He has a close circle of friends from his employment and friendship with a neighbor who assist with help for his parents.

Current Conditions/Chief Complaints/Concerns:
George recorded the onset of his pain about 6 months ago (March). He realizes that his overall physical activity level is limited with the responsibilities of his parents. George has not had any past therapeutic intervention for his current problems. He is asymptomatic of cardiovascular disease and has a resting heart rate in the normal range. George’s blood pressure puts him in the prehypertensive stage. Based on his exercise tests, George has very poor upper body strength along with a VO2 of 36.2, which is considered poor. His flexibility is also indicated as below average. The max work George can do is 10.3 METS. His PMHR is 173 bpm and his heart rate reserve (HRR) is 95 bpm. George chief complaint is lack of energy and pain in lower back, knee, and foot. His range of motion is also inhibited.

Functional Status and Activity Level:
George can perform all activities for daily living at home, work, and community settings.

Other Laboratory and Diagnostic Tests:
George has metabolic syndrome and is at risk for type 2 diabetes. His high-density lipoprotein (HDL) level is low and his LDL level is near optimal. George’s triglycerides are high along with his resting glucose, which indicates he has prediabetes. His body mass index (BMI) indicates that he is overweight and the size of his waist indicates obesity. He is asymptomatic of cardiovascular disease and has a resting heart rate in the normal range.

Using the sample write about another person in the same format.