University Physical Therapy Medical History Form

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UNIVERSITY PHYSICAL THERAPY MEDICAL HISTORY FORM
Name__________________________________________
Daytime phone #________________________
Occupation:_______________________________________________________________________________
Emergency Contact (name and phone number)____________________________________________________
 Name of primary physician______________________________________________________________
 Name of referring physician_____________________________________________________________
 When are you scheduled to return to your referring physician?__________________________________
 Have you seen anyone else for your current condition?
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Physician/MD
Chiropractor
Podiatrist
Orthopedic Surgeon
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Dentist
Neurologist
Physical Therapist
Other (specify: ___________)
Past Medical History:
Have you ever had any of the following conditions? Check all that apply.
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High blood pressure
Heart condition
Stroke
Osteoporosis
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Peripheral Neuropathy
Seizures/epilepsy
Vision problems
Diabetes
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Hearing problems
Fainting/dizziness
Emphysema
Frequent or severe headaches
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Bowel/bladder problems
Cancer
Arthritis
Asthma
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Other:___________________________________________________________________________________
Have you had any falls in the past year?
YES
NO
If so, about how many? ____________________
Do you have a history of fractures?
YES
NO
Where?__________________________________
Do you have any metal implants?
YES
NO
Where?__________________________________
Do you smoke?
YES
NO
How much per day?________________________
Do you exercise regularly?
YES
NO
How often?_______________________________
Do you have any known allergies?
YES
NO
Please list________________________________
Are you pregnant or think that you might be? YES
NO
Medications:
Please list any medications (prescribed or over-the-counter) or supplements that you are currently taking:
__________________________________________________________________________________________
__________________________________________________________________________________________
Surgeries: Please list all surgeries including dates:_________________________________________________
__________________________________________________________________________________________
Diagnostic Tests: Please check any tests or procedures that have been done for your current condition.
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X-rays
MRI
CT scan
Bone scan
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EMG
Blood work
Bone density
Ultrasound
Current Condition
 What is the problem you are here for?_____________________________________________________
___________________________________________________________________________________
 What is the date when the problem started? ________________________________________________
 Have you had similar symptoms before?___________________________________________________
 Have you had previous treatment for this condition?__________________________________________
Patient Signature____________________________________________ Date___________________________
Therapist Signature__________________________________________ Date___________________________

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