Medical History Questionnaire
Date: Name: Gender: Male Female Would Rather Not Disclose Age: Smoker: Yes NoIf yes, how many packs per day? Pregnant: Yes NoDue Date: Occupation: Do you regularly exercise? Yes No
Past Surgical History (list all including dates): Are you currently taking medication? Yes NoIf yes, please list: Have you had an x-ray, MRI, or other imaging study related to your current symptoms? Yes No If yes, please list test and date. Past Medical History: Please check each condition that you have been told you have (or had). Cancer Diabetes Kidney Disease Liver Disease Stroke Fractures or Broken Bones Heart Disease Angina/Chest Pain Ulcers Fibromyalgia Osteoporosis Osteoarthritis Rheumatoid Arthritis Pacemaker Allergies/Asthma Lung Disease Neuropathy Thyroid Dysfunction Daily Alcohol 3 or more glasses Muscle Disease History of Falls Hypertension (High Blood Pressure) Hypotension (Low Blood Pressure) Have you had a recent illness? If yes, please explain. Yes No Do you take blood thinners? Yes No Are you allergic to latex? Yes No Other Allergies:
Fever/Chills/Sweat Changes in Appetite Difficulty Swallowing Shortness of Breath Unexplained Weight Loss Headaches Hearing Problems Blurred Vision Dizziness or Vertigo Neck Pain and Radiating Pain Weakness in Arms Numbness/Tingling/Burning Sensation in Arms or Hands Shoulder Pain or Instability Elbow Pain or Instability Wrist/Hand Pain or Instability Low Back and Radiating Pain Numbess/Tingling/Burning Sensation in Legs or Feet Weakness in Legs Hip/Knee Pain or Instabilty Ankle/Foot Pain or Instabilty Unsteady Gait/WalkingIn the past month, have you often been bothered by feeling down, depressed, or hopeless? Yes No In the past month, have you often been bothered by little interest or pleasure in doing things? Yes No
Where are you currently having symptoms? What date (approximately) did your present symptoms start? How (gradually, suddenly, injury)? My symptoms are currently: Getting Better About the Same Getting Worse Have you received any treatment for this problem? Yes No Have you ever had this problem before? Yes No If so, how was this problem treated? How long did it take for you to feel better?How long are you able to sleep at night? Fine Moderate Difficulty Only with MedicationWhat is your personal goal for therapy?
Front Left 1 2 3 4 5 6 7 8 9 10 11
Front Right 1 2 3 4 5 6 7 8 9 10 11
Back Left 1 2 3 4 5 6 7 8 9 10 11
Back Right 1 2 3 4 5 6 7 8 9 10 11
Please answer the questions below based on the complaints for which you are primarily seeking treatment. Do you have increased pain with activity? Yes No Identify up to 3 different important activities that you are unable to do or are having difficulty with as a result of your problem. List them below: 1. 2. 3. What makes your symptoms better?Please check the activities which make your symptoms worse: Sitting Lying Down Standing Walking Stress Any other activities that make your symptoms worse? If you're in pain, on the scales below, please check the number which best represents the severity of your pain. 1 = No Pain, 10= Worst Pain Imaginable.
Best for the last 48 hours: 1 2 3 4 5 6 7 8 9 10Worst for the last 48 hours: 1 2 3 4 5 6 7 8 9 10What number represents your overall level of function? 1 = Cannot Do Anything, 10 = Able to do Everything. 1 2 3 4 5 6 7 8 9 10
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Document Name: Medical History Questionnaire
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