Medical History Questionnaire
Gender: Male Female Would Rather Not Disclose
Smoker: Yes No (If yes, how many packs per day?)
Pregnant: Yes No (Due Date)
What do you do to stay active during the week? How often?
Are you currently taking any medications/supplements? 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 Bone Fractures Osteoporosis Osteoarthritis Rheumatoid Arthritis Fibromyalgia Muscle Disease History of Falls Ulcers Allergies Asthma Lung Disease Neuropathy Thyroid Dysfunction Stroke Angina/Chest Pain Pacemaker/Cardiac Device Heart Disease Daily Alcohol (3 or more glasses) Hypertension (High Blood Pressure) Hypotension (Low Blood Pressure)
Any other? (If yes, please explain.) Yes No
Please list any previous surgeries, medical procedures, and/or hospitalizations with dates:
Do you take blood thinners? Yes No
Are you allergic to latex? Yes No
Currently I am experiencing: (check all that apply to your current symptoms)
Fever/Chills/Sweat Changes in Appetite Difficulty Swallowing Shortness of Breath Unexplained Weight Loss Headaches or Migraines Hearing Problems Blurred Vision Dizziness or Vertigo Sudden Fainting Spells Weakness in Legs Unsteady Gait/Walking Recent Increase in Stress or Anxiety Bladder/Bowel Changes Numbness/Tingling/Burning Sensation in Arms or Hands Numbness/Tingling/Burning Sensation in Legs or Feet Other
In 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 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: Getting Better About the Same Getting Worse
Have you ever had this problem before? Yes No
Have you already received treatment for this problem? Yes No
If so, how was this problem treated and was it successful?
Does your problem prevent you from getting a full night's sleep? Yes No
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, 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? 0 1 2 3 4 5 6 7 8 9 10
Using the scale above, which number represents your current level of activity? 0 1 2 3 4 5 6 7 8 9 10
What is your personal goal for therapy?
How did you hear about us? Doctor Referral Friend Facebook Instagram Google
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Document Name: Medical History Questionnaire
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