Optimum Health and Wellness

Medical History Questionnaire

Date: Name:

If yes, how many packs per day?
Due Date:
Do you regularly exercise?

Past Surgical History (list all including dates):
Are you currently taking medication?

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).

Have you had a recent illness? If yes, please explain.

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 date (approximately) did your present symptoms start?

How (gradually, suddenly, injury)?

My symptoms are currently:

Have you received any treatment for this problem?
Have you ever had this problem before?

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?

What is your personal goal for therapy?

Body Chart

Please consult the chart then check the corresponding boxes below to indicate where your symptoms are.


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 or are having difficulty with as a result of your problem. List them below:
What makes your symptoms better?

Please check the activities which make your symptoms worse:

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:

Worst for the last 48 hours:

What number represents your overall level of function? 1 = Cannot Do Anything, 10 = Able to do Everything.


Leave this empty:

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Document name: Medical History Questionnaire
lock iconUnique Document ID: c811255688a8e20dc864d5bb095fbbaac2885a16
Timestamp Audit
January 27, 2020 2:45 pm AKDTMedical History Questionnaire Uploaded by Optimum Health and Wellness - emily@ohwpt.com IP
June 8, 2020 3:32 pm AKDTNikki Brown - nikki@ohwpt.com added by Christopher Comstock - emily@ohwpt.com as a CC'd Recipient Ip:
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: