Patient Medical History

Please fill this form out in its entirety to the best of your ability. All information is protected by medical confidentiality laws.

Full Legal Name: I prefer to be called:

How did you find out about us?

Did a physician refer you to physical therapy? / Yes / No

Name of physician:

Do you smoke cigarettes? / Yes / No / How many pks/day?
Do you drink alcohol? / Yes / No / How often? / drinks per day or week (circle one)
Do you use any recreational drugs? / Yes / No / What drug(s) and how often?

Occupation: Employer:

Date of Injury: Where is your injury?

How did you sustain your injury?

What recreational/occupational activities are limited?

Did you have surgery for this injury? / Yes / No
If yes: Date: / Procedure:

What is your goal from physical therapy?

If you have pain, how severe is it when it is at its worst? (Please check one)
0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
No pain / Worst pain imaginable
If you have pain, how severe is it when it is at its best? (Please check one)
0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
No pain / Worst pain imaginable
Describe your symptoms (Please check all that apply): / Getting Better / Staying the Same / Getting Worse
Aching / Sharp / Burning / Tingling / Constant / Intermittent / Only with movement

Which movements/activities increase your symptoms?

What decreases your symptoms?

Since the onset of your symptoms have you had:
Difficulty with bowel or bladder function? / Yes / No / Intractable night pain/sweats? / Yes / No
Unexplained weight change? / Yes / No / Numbness? / Yes / No
Dizziness/fainting? / Yes / No / Weakness? / Yes / No
Fever/chills? / Yes / No / Malaise (overall “sick” feeling)? / Yes / No
Please mark any of the following that you now have or have ever had. Briefly describe as necessary.
Heart Problems: / Cancer:
Respiratory Problems: / Renal Disease:
Neurological Disorder: / Blood Disorder:
Eating Disorder: / Anemia:
Osteoarthritis: / Epilepsy/Seizures:
Rheumatoid Arthritis: / Depression:
None of the above

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Are you diabetic? / Yes / No
If so: Are you insulin dependent? / Yes / No / Is your diabetes well controlled? / Yes / No
Do you currently have exercise induced asthma (EIA)? / Yes / No
If so: Do you have your inhaler with you? / Yes / No (please bring it with you every visit)
Do you currently have high blood pressure? / Yes / No
If so, is your hypertension currently well controlled? / Yes / No
Do you have any infectious diseases? / Yes / No / Please describe:
Do you have any psychological disorders? / Yes / No / Please describe:
During the past month have you often been bothered by feeling down, depressed, or hopeless? / Yes / No
During the last month have you often been bothered by little interest or pleasure in doing things? / Yes / No

Please list any medications with dosages that you currently are taking:

Please list any known allergies that you may have:

Please list any other medical or surgical history of which we should be aware:

Do you have any stairs at home? / Yes / No / If so how many? / steps or flights (circle one)
What visit frequency are you expecting?
Just a one time visit for some quick education on diagnosis and self-management
Extensive home program with occasional check-in to test and progress (usually once every week or two)
I prefer to do the majority of my rehabilitation under direct supervision (usually 2-3 times per week)
I have no expectations regarding frequency

Any additional information?

I attest that the information provided on this form is accurate to the best of my knowledge as of this date. If any information provided on this form changes, I understand that it is my responsibility to provide that updated information to Baarspul Physical Therapy before any additional physical therapy sessions are provided.

Signature of Patient/Guardian/Responsible Party Date

Signature of Baarspul PT Witness Date

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