Medical History Questionnaire - CTI Physical Therapy
Medical History Questionnaire Date:
Name _______________________________ Age_________ DOB__________ Height ________ Weight ________
Work/Employer_________________________ Referring Physician:
Family Physician (First & Last Name) ________________________________________
Main Problem (How & When Pain/Symptoms Occur):____________________________________________________
________________________________________________________________________________________________
List of Medications and Supplements currently taking: ____________________________________________________
________________________________________________________________________________________________
Allergies to Medications ____________________________________________________________________________
Tests Regarding Current Condition (Circle Any or All) X-RAY MRI CT-SCAN EMG
When:___________ Where:___________________________________________________________________
Fracture (All): ______________________________________________________________________________
Surgeries (All): _____________________________________________________________________________
Medical History (Circle YES or NO)
Self Immediate Family Self Immediate Family
Heart Disease Yes No Yes No Hepatitis Yes No Yes No
High Blood Pressure Yes No Yes No Thyroid Condition Yes No Yes No
Stroke Yes No Yes No Diabetes Yes No Yes No
Cancer Yes No Yes No Arthritis Yes No Yes No
Kidney Yes No Yes No
Do You Have A History Of:
Allergies/Asthma Yes No Seizures Yes No
Tuberculosis Yes No Headaches Yes No
In The Past 3 Months, Have You Had or Have:
A Change In Your Health Yes No Nausea/Vomiting Yes No
Fever/Chills/Sweats Yes No Unexplained Weight Change Yes No
Numbness/Tingling Yes No Changes in Appetite Yes No
Difficulty Swallowing Yes No Changes in Bladder Functions Yes No
Shortness of Breath Yes No Upper Respiratory Infection Yes No
Dizziness Yes No Urinary Tract Infection Yes No
Are You Currently:
Pregnant Yes No Under Stress Yes No
Depressed Yes No Have A Pacemaker Yes No
How Are You Sleeping At Night? (Check One) ( ) Fine ( ) Difficulty ( ) Only With Medication
Are Your Symptoms: (Check One) ( ) Getting Worse ( ) The Same ( ) Getting Better
Please Rate Severity Of Your Pain By Circling a Number: No Pain 0 1 2 3 4 5 6 7 8 9 10 Unbearable
Email Address_________________________________________ Emergency Contact: _____________________________
Relationship: _____________________________________________ Phone: ________________________
Who would you like to allow access to your medical information: ________________________________________________
The Above Statements Are True To The Best Of My Knowledge: Signature _______________________________________
Date_____________________
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