Forms

A pdf of the Patient History Form may be downloaded here:

Medical History Form

Patient Medical History
  • Name*Full Name
    0
  • Date*Today's date
    1
  • Present / Past History*Check if you have every had
    Arthritis/swollen joints
    Gout
    Asthma, Bronchitis. or Emphysema
    High Blood Pressure
    Angine, Coronary Heart Disease
    Heart Attack or Surgery
    Anemia
    Infectious Diseases (i.e. Active Tuberculosis)
    Bowel/Bladder Problems
    Osteoporosis
    Breathing difficulties / Shortness of breath
    Pacemaker
    Blood Clot/Emboli
    Psychological/Emotioanl Problems
    Cancer or Chemotherapy / Radiation
    Problems Sleeping
    Diabetes
    Stroke / TIA
    Epilepsy / Seizures
    Thyroid Problems
    2
  • Medications*Check if you are taking any of the following
    Anit-inflammatory
    Muscle Relaxers
    Pain Medication
    Other
    3
  • Do you have any allergies?*Y or N
    Yes
    No
    5
  • Have you had any surgeries?*Y or N
    Yes
    No
    7
  • Do you smoke?*Y or N
    Yes
    No
    9
  • Are you aware of your diagnosis?*Y or N
    Yes
    No
    10
  • Are you pregnant?*Y or N
    Yes
    No
    11
  • What is your main problem/complaint?*
    12
  • Estimated Injury Date*
    13
  • What are your goals/expectations for physical therapy?*
    14
  • Have you had any of the following medical or therapy services for this condition?*select one or more
    Physical Therapy
    Occupational Therapy
    Massage
    Chiropractor
    MRI
    X-Rays
    CT Scan
    EMG/NCV
    Neurologist
    Orthopedist
    General Practitioner
    Podiatrist
    Myelogram
    Other
    15
  • Are you currently working?*
    Full time
    Part Time
    Modified Duty
    Not working
    Retired
    17
  • Is there an attorney involved in this case?*Y or N
    Yes
    No
    18
  • Would you like to speak to a Social Worker or Vocational Rehabilitation Counselor?*Y or N
    Yes
    No
    19
  • Date of next (referring) doctor's appointment*
    20
  • 21