Valleycare Physical And Sports Medicine History Form
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4Physical and sPorts medicine history form
PERSONAL INFORMATION
1. Name ______________________________________________
2. Prefer to be called _____________________________________
3. Date of Birth ________/________/________ _____________
4. Sex q M q F
5. Primary language __________________________________
Do you understand English? q yes q no
Can you read English? q yes q no ________________
Can you write English? q yes q no
SOCIAL HISTORY
6. Any customs or religious beliefs that might affect care? q Yes q No
Please explain ________________________________________________________________________________________________________
7. With whom do you live?
q alone
q with spouse
q with spouse and others
q with child
q in a group setting
q with personal care attendant
q other
8. Employment Information (Please check appropriate boxes)
q works full time
q works part time
q homemaker
q student
q retired
q unemployed
9. Occupation ___________________________________________________________________________________________________________
10. Physical demands of job _____________________________________________________________________________________________
Approximate number of hours sitting _____________ standing _______________
Approximate amount of weight you have to lift _________________
MISCELLANEOUS INFORMATION
11. Do you or your caregiver need information on any of the following:
q current diagnosis
q medications q diet
q activity
q equipment
q transportation
q community resources
q other ____________________________________________
12. How would you rate your or your caregiver’s motivation to learn about your condition?
q high
q moderate
q minimal
q none
13. Do you have family, emotional, home concerns, or any special needs that may impact your care and that need
to be addressed? q Yes q No
14. Do you learn better by
q Reading/handout
q Verbal description/ Discussion
q Other?
LIVING ENVIRONMENT
15. Does your home have:
q stairs, no railing
q stairs, with railing
q ramps
q elevator
q uneven terrain
q any obstacles_________________________________________
16. Do you use any of the following?
q cane
q walker
q manual wheelchair
q motorized wheelchair
GENERAL HEALTH
17. Please rate your general health:
q excellent
q good
q fair
q poor
18. Do you wear glasses/contacts? q yes q no
19. Do you wear hearing aids? q yes q no
20. Do you have any known allergies? q yes q no If yes, please list _______________________________________________
21. Do you exercise beyond normal daily activities/ chores? q yes q no
If yes, please describe the activities and approximately how many minutes; how many times per day
you exercise? ________________________________________________________________________________________________________
CONTINUED ON OTHER SIDE
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Parent category: Medical