Professional Physical Therapy



PATIENT MEDICAL HISTORY FORMName: ____________________________________Treating Physician: ______________________________Primary Care Physician: ____________________ Date of 1st Doctors Visit for this Injury:_____________Last Day Worked Due to this Injury (if applicable):_____________________________________________Date Returned to Work after Injury (if applicable):______________________________________________Have you retained an attorney as a result of your injury? YES NO Referral Source: Surgeon Rehab MD Other:_________________________________________Have you had Surgery for this Injury?YES NO Number of Surgeries:__________________Type of Surgery(ies):_______________________________________________________________________Are you currently taking any medications (prescription and/or over the counter medicines): Anti-InflammatoriesYESNOIf YES, please specify:_________________________________________Muscle RelaxersYESNOIf YES, please specify:_________________________________________Pain MedicationYESNOIf YES, please specify:_________________________________________OtherYESNOIf YES, please specify:_________________________________________Have you had any of the following diagnostic, medical or rehabilitative services for this injury/episode?YES NOYES NOChiropractor____ ____General Practitioner____ ____EMG/NCV____ ____CT Scan____ ____Massage Therapy____ ____MRI____ ____Myelogram____ ____Neurologist____ ____Occupational Therapy____ ____Orthopedist____ ____Physical Therapy____ ____Podiatrist____ ____Emergency Room ____ ____X-Rays____ ____Do you now or have you ever had any of the following? YES NO YES NO Asthma, Bronchitis, or Emphysema ____ ____ High Blood Pressure ____ ____Anemia ____ ____ Shortness of Breath/Chest Pain ____ ____Heart Attack or Surgery ____ ____ Diabetes ____ ____Coronary Heart Disease or Angina ____ ____ Thyroid Trouble/Goiter ____ ____Gout ____ ____ Cancer/chemotherapy/Radiation ____ ____Dizziness or Fainting ____ ____ Weakness ____ ____Emotional/Psychological Problems ____ ____ Infectious Diseases ____ ____Hernia ____ ____ Bowel or Bladder Problems ____ ____Numbness or Tingling ____ ____ Allergies ____ ____Severe or Frequent Headaches ____ ____ Elbow/Hand Injury ____ ____Osteoporosis ____ ____ Vision or Hearing Difficulties ____ ____ YES NO YES NONeck Injury/Surgery ____ ____ Stroke/TIA ____ ____Sleeping Problems/Difficulties ____ ____ Back Injury/Surgery ____ ____Blood Clot/Emboli ____ ____ Leg/Ankle/Foot Injury/Surgery ____ ____ Knee Injury/Surgery ____ ____ Epilepsy/Seizures ____ ____ Do you have a Pacemaker? ____ ____ Arthritis/Swollen Joints ____ ____Varicose Veins ____ ____ Any Pins or Metal Implants? ____ ____Are You Pregnant? ____ ____ Joint Replacement ____ ____Weight Loss/Energy Loss ____ ____ Do You Smoke? ____ ____Please list any additional information that would assist us in providing care to you? ____________________________________________________________________________________________________________________________________________________________________________________Are you aware of your diagnosis (what you are being treated for at our clinic)?Yes NoWhat are your expectations/goals? ____________________________________________________________________________________________________________________________________________________________________________________By my signature below, I certify that the information I have provided above is complete, accurate and truthful to the best of my knowledge.Patient/Legal Guardian Signature: _______________________________ Date: _______________________Patient/Legal Guardian Name: _______________________________________________________________Therapist’s Signature:___________________________________________ Date: ______________________ ................
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