Patient History Form
ADVERTISEMENT
1PATIENT HISTORY
Name:
Primary Care /General Doctor: ______________________________ Height: _______ Weight: _______
Date of Onset of Pain: ______________ Date of Injury: _____________ Date of Surgery: ____________
□
□
Pain Status:
New Injury
Chronic Injury
What is your primary concern? ___________________________________________________________
□
□
□
Pain Location: ____________________________________ Treatment Side
N/A
Left
Right
:
Pain Scale:
0= None
5= Moderate
10= Extreme
0
1
2
3
4
5
6
7
8
9
10
□
□
□
□
□
□
□
□
□
□
□
At worst:
□
□
□
□
□
□
□
□
□
□
□
Current:
□
□
□
□
□
□
□
□
□
□
□
At best:
□
□
□
□
Aggravating Factors:
Sitting
Standing
Walking
Lying down
□
□
□
□
Stairs – up
Reaching
Lifting
Getting up from a chair
What makes it feel better? _____________________________ Feel worse? ______________________
□
□
□
□
History of Similar Symptoms:
No
Yes
History of Falls in last year:
No
Yes
□
□
□
□
Home Health Care:
No
Yes
Hospitalization in last 3 months?
No
Yes
Occupation: ______________________________
□
□
Medical History:
Fracture or Suspected Fracture
Rheumatoid Arthritis
□
□
□
Alzheimer’s
High Blood Pressure
Traumatic Brain Injury
□
□
□
Cardiovascular Disease
History of Cancer
Allergies: _____________
□
□
□
Cauda Equina Syndrome
Huntington’s
Unexplained Weight Loss
□
□
□
CVA / Stroke
Immunosuppression
Pacemaker
□
□
□
Current Infection
Lupus
Pregnant
□
□
□
Diabetes Mellitus Type 1
Muscle Dystrophy
Seizures
□
□
□
Diabetes Mellitus Type 2
Osteoarthritis
HIV/AIDS
□
□
□
Hemophilia
Hepatitis B/C
Other: _______________
□
□
□
□
□
Diagnostics:
X-Ray
MRI
CT Scan
Myelogram
Diagnostic Ultrasound
Results of Imaging: _____________________________________________________________________
□
Medications:
See attached ____________________________________________________________
_____________________________________________________________________________________
Patient Goals for Physical Therapy: _______________________________________________________
_____________________________________________________________________________________
Patient Signature
Date
__________________________________________
______________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical