Hamilton Physical Therapy Services, Lp Patient Intake And Consent Form (Page 3 of 4) in pdf

M5.002A

Hamilton Physical Therapy Services, LP

MEDICAL HISTORY FORM

PATIENT NAME: _____________________________________________

TODAY’S DATE: _________________________

REFERRING PHYSICIAN’S NAME: ______________________________ DATE OF INJURY OR ONSET: ____________

PRIMARY CARE PHYSICIAN’S NAME: __________________________ DATE OF NEXT MD APPT: ______________

CAUSE OF INJURY OR ONSET: ________________________________

WHAT IS YOUR REASON FOR ATTENDING THERAPY: _______________________________________________

____________________________________________________________________________________________________________

___________________________________________________________________________________________________________

BECAUSE OF YOUR PROBLEM, WHAT SPECIFIC ACTIVITIES ARE YOU HAVING DIFFICULTY WITH?

______________________________________________________________________________________________

WHAT ARE YOUR PERSONAL GOALS/OUTCOMES YOU HOPE TO ACHIEVE FROM THERAPY?

______________________________________________________________________________________________

SURGICAL/HOSPITALIZATION/THERAPY HISTORY:

HAVE YOU RECENTLY BEEN HOSPITALIZED OR HAD SURGERY?

YES/NO

IF YES, WHEN

AND WHY_______________________________________________________________________________________________

LIST YOUR SURGICAL HISTORY________________________________________________________________________

__________________________________________________________________________________________________________

HAVE YOU HAD PRIOR PHYSICAL/OCCUPATIONAL THERAPY FOR THIS CONDITION? (circle one) YES/NO

WHAT WAS DONE? / WHAT WERE THE RESULTS?:

_________________________________________________________________________________________________________

CURRENT HEALTH STATUS:

DO YOU CURRENTLY USE TOBACCO?(cirlce one) YES/NO, IF YES HOW MUCH?_____________________

DO YOU WEAR GLASSES/CONTACTS? YES/NO

DO YOU CURRENTLY HAVE ANY “FLU TYPE” SYMPTOMS (I.E. FEVER, COUGHING)?

YES/NO

IF YES, WHAT SYMPTOMS: ______________________________________________________________________________

DO YOU HAVE ANY OPEN CUTS, LESIONS OR WOUNDS?

YES/NO

IF YES, WHERE: _____________

CURRENT MEDICATIONS: _______________________________________________________________________________

______________________________________________________________________________________________________________________________________

Hamilton Physical Therapy Services, Lp Patient Intake And Consent Form Page 3