Health History Form
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1Health History Form
To insure you receive a complete and thorough evaluation, please provide us with
important background information on the following form. If you do not understand a
question, your therapist will assist you.
NAME: ___________________________________________DATE: _______________
GENERAL HEALTH STATUS: (Rate your overall health)
Excellent
Good
Fair
Poor
WHAT ARE YOUR CHIEF COMPLAINT(S) / PROBLEM(S)? _____________________________________________________
WHAT PHYSICIAN REFERRED YOU FOR THIS INJURY / EPISODE? _____________________________________________
WHEN DID YOUR SYMPTOMS BEGIN? (Specific date if possible) ______________________________
HOW DID YOUR INJURY / PROBLEM OCCUR? ______________________________________________________________
WHAT AGGRAVATES YOUR SYMPTOMS? (Check all that apply)
Please mark and localize your area
SITTING
SQUATTING
of pain on the body chart below
GOING TO / RISING FROM SITTING
LYING DOWN
SLEEPING
WALKING
COUGHING / SNEEZING
UP / DOWN STAIRS
TAKING A DEEP BREATH
REACHING OVERHEAD
LOOKING UP OVERHEAD
REACHING IN FRONT OF BODY
SWALLOWING
REACHING BEHIND BACK
STRESS
REACHING ACROSS BODY
SUSTAINED BENDING
TALKING / CHEWING / YAWNING
RECREATION / SPORTS
REPETITIVE ACTIVITIES
STANDING
HOUSHOLD ACTIVITIES
OTHER ____________________________
WHAT RELIEVES YOUR SYMPTOMS? (Check all that apply)
SITTING
WEARING A SPLINT / ORTHOSIS
HEAT
WALKING
COLD
EXERCISE
STRETCHING
LYING DOWN
WEARING A SPLINT
MASSAGE
REST
MEDICINE
STANDING
NOTHING
OTHER ____________________________
DIAGNOSTIC TESTING FOR THIS INJURY / EPISODE: (Check all that apply)
MRI
CT Scan
EMG
Other: ____________________________
PAST MEDICAL HISTORY
SURGICAL HISTORY: (Please list any recent/relevant past surgeries to current
problem)
Have you ever had / been diagnosed with any of the
following? (Check all that apply)
_________________________________________DATE______________
_________________________________________DATE______________
DEPRESSION
HIGH BLOOD PRESSURE
o
STROKE
LUNG PROBLEMS
_________________________________________DATE______________
o
DIABETES
THYROID PROBLEMS
NO SURGERIES TO DATE
o
ARTHRITIS
MENTAL / BEHAVIORAL
o
HEAD INJURY
EPILEPSY / SEIZURES
o
ALLERGIES
MULTIPLE SCLEROSIS
Circle Your Pain Scale
o
LIGHTHEADED
BROKEN BONE
o
HEART PROBLEMS
BLOOD DISORDERS
NO PAIN
1 2 3 4 5 6 7 8 9 10
UNBEARABLE
HEART PROBLEMS
o
KIDNEY PROBLEMS
CIRCULATION PROBLEMS
o
HISTORY OF FALLS
o
INFECTIOUS DISEASES
INNER EAR DISORDERS
CURRENT MEDICATIONS: (Or please give us a separate list)
VISION PROBLEMS
VERTIGO
__________________________________________________________________
OSTEOPOROSIS
RHEUMATOID ARTHRITIS
o
PARKINSON’S DISEASE
__________________________________________________________________
PRODUCTIVE COUGH
VASCULAR PROBLEMS
ANOREXIA
o
____________________________________________
NIGHT SWEATS
BLOODY SPUTUM
o
By signing this form I agree that the information given is true.
o
FEVER
WEIGHT LOSS
Signature_________________________________ Date _____________
CANCER (TYPE) ________________
OTHER: ____________________
DO YOU HAVE A PACEMAKER? YES NO
ARE YOU CURRENTLY PREGNANT? YES NO
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