Cooperative Performance & Rehabilitation Past Medical History Form
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1Cooperative Performance & Rehabilitation
Past Medical History Form
Name: ____________________________________________ Date: __________________________________
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Occupation: ______________________________ Status:
Full-time
Part-time
Other ______
Onset of current condition: ____________________
Main Complaints, Restrictions and Pain Alleviations:
__________________________________________________________________________________________
__________________________________________________________________________________________
If you are having pain, please rate the severity on a 0-10 scale, where 0 is no
Please indicate the location of your symptoms such as,
pain and 10 is the most severe pain:
pain, numbness or other:
At worst:
0 1 2 3 4 5 6 7 8 9 10
Current:
0 1 2 3 4 5 6 7 8 9 10
At best:
0 1 2 3 4 5 6 7 8 9 10
Pain description: _________________________________
_______________________________________________
Medical History:
Please mark if you have ever had any of the following and
Describe:
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Osteoporosis
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Cardiovascular Disease
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Diabetes 1
Diabetes 2
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Surgical History
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Previous Therapy
○ Other
Current Medications:
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Arthritis
Anemia
Prescriptions
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Nausea or vomiting
Headaches
Over the Counter
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Dizziness/light headed
Head Injury/Concussion
Herbals
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Anxiety
Depression
Vitamins/Mineral
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Hearing Loss
Hernia
Other ________________________
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Fatigue/Weakness
Fibromyalgia
List of Medications: __________________________
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Seizures/Epilepsy
Thyroid Problems
___________________________________________
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Numbness/Tingling
Any other conditions
___________________________________________
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Asthma
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Shortness of Breath
__________________________________________________________________
Diagnostics/X-ray Testing:
__________________________________________
_____________________
Patient/Parent/Guardian Signature
Date
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