Medical History Questionnaire

PLEASE DO NOT PRINT THIS FORM

Name *

First

Middle

Last

Are you currently receiving, or have you received Home Health Care Services this year? Please include episodes of at home nursing care. *

When were you discharged? *

The purpose of this form is to help the Physical Therapist understand your health status. Please complete the questionnaire to the best of your ability. This form will be a part of your medical record. A Medical History Questionnaire is required at the opening of each new case.

Referring Physician

Primary Care Physician

Please best describe why you have been referred to Physical Therapy. Why are you here to see us today? *

Have you had any tests or previous treatments for this episode in the past year? Please list any recent x-rays, MRIs, CT scans,etc *

Do you now, or have you ever had any of the following: *

Pacemaker
Thyroid Problems
Unexplained Weight Loss
Heart Problems
High Blood Pressure
Stroke
Diabetes
Dizziness
Fainting
Severe Headaches
Cancer
Osteoporosis
Seizures
None of the above

Please list any surgeries or falls pertinent to this episode/ injury. Include dates: *

If you are experiencing pain, please describe by selecting ALL that apply: *

None
Constant
Intermittent
Sharp
Dull
Aching
Stabbing
Numbness
Pins/Needles

Rate your pain over the last week on a scale of 0 – 10
(0 = No pain at all, 10 = Need to go to the emergency room):

Pain level when you feel the best (check one) *

Pain level when you feel the worst (check one) *

Current pain level (check one) *

Please describe how you are most functionally limited by this injury/Episode (check all that apply): *

Lifting/Carrying
Moving/ Changing Positions
Walking
Self-care/ Household activities
Other

If other, please explain

What percentage of your daily activities are limited (affected) by this episode/Injury (check one): *

10%
20%
30
40%
50%
60%
70%
80%
90%
100%

TERMS OF ACCEPTANCE and SIGNATURE

I, the patient/guardian for this Medical History Questionnaire, warrant the truthfulness of the information provided in this application.

Electronic Signature *

Patient/Guardian

Acceptance Checkbox *

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

Date: *

TERMS OF ACCEPTANCE and SIGNATURE

Hours of Operation

Monday - Friday

8:00am - 4:30pm

Office Location

Progressive
Physical Therapy

Are you ready to start feeling better?

Patient Resources

Quick Links

Medical History Questionnaire

TERMS OF ACCEPTANCE and SIGNATURE

Hours of Operation

Monday - Friday

8:00am - 4:30pm

Office Location

ProgressivePhysical Therapy

Are you ready to start feeling better?

Call Today: (520) 648-3132

Patient Resources

Quick Links

Progressive
Physical Therapy