Patient Medical History Form

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PATIENT HISTORY FORM
Date: _____________
Name: ________________________________________
Height: ________________ Weight: ________________
PRESENT INJURY
Please specify the body region(s) involved for which you are seeking physical therapy (i.e. left knee, right hand)
__________________________________________________________________________________________
Date of Injury or Estimated Date of Onset: __________________
Have you received previous treatment for this condition?
Yes
No
If yes, please circle all that apply:
Medicine
Injections
Surgery
Chiropractic
Physical Therapy
Other: __________________
Severity of your pain?
Mark the point on the line, 0(least) and 10(worst) which best describes your current pain level.
____________________________________________________________________________________________
0
1
2
3
4
5
6
7
8
9
10
SOCIAL HISTORY
Do you smoke?:
No
Yes
MEDICAL HISTORY
Medications: Please circle medications that you are currently taking:
Pain
Anti-inflammatory
Blood Thinner
Blood Pressure Meds
Surgeries: Please list pertinent past surgeries and dates:
____________________________________________________________________________________________
____________________________________________________________________________________________
Allergies: List all allergies (medications, tapes, latex, etc.)
_____________________________________________________________________________________________
Fall Risk: Have you had any loss of balance or falls in the past 12 months?
No
Yes
How many? _________
Please circle Yes or No if you have any of the following conditions? If yes, please explain.
Constitutional:
Genitourinary:
Recent weight changes
N Y _____________
Females: Could you be pregnant? N Y_____________
Night sweats, pain, fevers
N Y _____________
Gastrointestinal:
Nausea/vomiting
N Y ______________
Cardiovascular:
Chest pain/heart trouble
N Y ______________
Abdominal pain
N Y ______________
High/low blood pressure
N Y ______________
Pacemaker
N Y ______________
Neurological:
Convulsion/seizures
N Y ______________
Numbness/tingling
N Y ______________
Respiratory:
Chronic Obstructive Pulmonary Disease
Head/spinal injury
N Y ______________
(COPD)
N Y ______________
Dizziness
N Y _____________
Asthma
N Y ______________
Psychiatric:
Musculoskeletal:
Confusion/memory loss
N Y ______________
Muscle pain/cramps
N Y ______________
Muscle weakness
N Y ______________
Other:
Stiffness/swelling joints
N Y ______________
Cancer
N Y ______________
Rheumatoid arthritis/Joint pain
N Y ______________
HIV-AIDS
N Y ______________
Fibromyalgia
N Y ______________
Hepatitis
N Y ______________
Endocrine:
Diabetes
N Y ______________

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