Optimum Health and Wellness

Medical History Questionnaire


Name:

Gender:

Age:

Smoker:

(If yes, how many packs per day?)

Pregnant:

(Due Date)

Occupation:

What do you do to stay active during the week? How often?
 

Are you currently taking any medications/supplements?


If yes, please list:

Have you had an x-ray, MRI, or other imaging study related to your current symptoms?


If yes, please list test and date.

Past Medical History: Please check each condition that you have been told you have (or had).







Any other? (If yes, please explain.) 


Please list any previous surgeries, medical procedures, and/or hospitalizations with dates:

Do you take blood thinners?

Are you allergic to latex?

Other Allergies:

Currently I am experiencing: (check all that apply to your current symptoms)







In the past month, have you often been bothered by feeling down, depressed, or hopeless?

In the past month, have you often been bothered by little interest or pleasure in doing things?

Current Symptoms:

Where are you currently having symptoms? What brought you in to Physical Therapy?

What date (approximately) did your present symptoms start?

How did it start? (gradually, suddenly, injury)

My symptoms are currently:

Have you ever had this problem before?

Have you already received treatment for this problem?

 

If so, how was this problem treated and was it successful?

Does your problem prevent you from getting a full night's sleep?

 

Please answer the questions below based on the complaints for which you are primarily seeking treatment. 

Do you have increased pain with activity?

Identify up to 3 different important activities that you are unable to do, having difficulty with, or that increases your symptoms.

1.
2.
3.

What makes your symptoms better?




Using the scale above, which number represents your current level of pain?





Using the scale above, which number represents your current level of activity?

What is your personal goal for therapy?

How did you hear about us?

Leave this empty:

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Signature Certificate
Document name: Medical History Questionnaire
lock iconUnique Document ID: c6dea8c7166a4d87f9e50c91df8f31d88fae80eb
Timestamp Audit
January 27, 2020 2:45 pm AKDTMedical History Questionnaire Uploaded by Optimum Health and Wellness - elizabeth@ohwpt.com IP 206.223.197.206
June 8, 2020 3:32 pm AKDTNikki Brown - nikki@ohwpt.com added by Christopher Comstock - emily@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206
August 28, 2020 9:34 am AKDTNikki Brown - nikki@ohwpt.com added by Optimum Health and Wellness - emily@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206
November 23, 2020 2:57 pm AKDTNikki Brown - nikki@ohwpt.com added by Optimum Health and Wellness - emily@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206
June 10, 2021 2:58 pm AKDTNikki Brown - nikki@ohwpt.com added by Optimum Health and Wellness - emily@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206
June 10, 2021 3:16 pm AKDTNikki Brown - nikki@ohwpt.com added by Optimum Health and Wellness - emily@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206
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March 30, 2022 8:28 am AKDTElizabeth McCallister - elizabeth@ohwpt.com added by Optimum Health and Wellness - elizabeth@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206
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April 6, 2022 12:18 pm AKDT Document owner elizabeth@ohwpt.com has handed over this document to jaimee@ohwpt.com 2022-04-06 12:18:15 - 206.223.197.206
April 6, 2022 12:18 pm AKDTElizabeth McCallister - elizabeth@ohwpt.com added by Jaimee Watson - jaimee@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206
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April 6, 2022 5:28 pm AKDTElizabeth McCallister - elizabeth@ohwpt.com added by Optimum Health and Wellness - elizabeth@ohwpt.com as a CC'd Recipient Ip: 206.223.210.102
April 6, 2022 5:28 pm AKDTJaimee Watson - jaimee@ohwpt.com added by Optimum Health and Wellness - elizabeth@ohwpt.com as a CC'd Recipient Ip: 206.223.210.102