Physical Therapy Medical History Form

Patient Medical History

Patient Name _______________________Date   _______________

Are you presently working? □ Yes  □ No    

 Date of next physicians visit _______________

1. Date of injury/Onset _______________________
2. Have you ever had these symptoms before      □ Yes        □ No

3. Check all that apply to your symptoms:

□ Work related injury        □ Reoccurrence of previous injury □ Motor vehicle accident

□ Injury related to lifting   □ Athletic or recreational injury       □ Cause unknown

□ Other_____________________________________________________________________

Have you had a related surgery?   □ Yes   □ No       when: ___________________________

Do you currently have or have had in the past any of the following?

□ Heart Attack  □ Heart Disease   □ Heart Palpitations  □ Chest Pain Angina

□ High Blood pressure Are you on blood thinners □ Yes    □ No   Pacemaker □ Yes    □ No  

□  Diabetes     □  Type 1 juvenile      □  Type 2 Adult onset              □ Do you take insulin?

□  Asthma/Breathing Difficulties         Do you use a rescue inhaler     □ Yes   □ No     

 Are you pregnant?  □ Yes   □ No       Do you smoke?                          □ Yes   □ No       

□  Headaches    □  Dizziness/Fainting      □  Ringing in your ears    □  Seizures  

□ Kidney problems    □  Cancer          □ Hernia  □ Special diet guidelines

□ Bowel/Bladder abnormalities  □ Liver/Gallbladder problems    

□ Allergies to aspirin  □ Allergies to heat  □ Allergies/poor tolerance to cold

□ Recent fractures          □ Recent Surgery □ Metal implants □ Rheumatoid arthritis

□ Skin abnormalities □ Sexual dysfunction □ Nausea/Vomitting

□ Other_______________________________________________________________

               _______________________________________________________________

         Patient Medical History

Patient Name ______________________________                                 Date   _______________

If you answered yes to any of the previous questions – please explain and give approximate date:

________________________________________________________________________________________
_______________________________________________________________________________________

Are you currently taking any medications?  □ Yes   □ No       If so – please list below

What is the intensity of your pain on a scale of 1 to 10. With 0 being 

In the rare instance of an emergency who should we contact?

Name _____________________Phone ___________________

Do you participate in any sport, activities, or exercise program on a regular basis □ Yes   □ No      

                                Please show us where your pain is on the illustration above