MEDICAL HISTORY

Patient Name:______Age:______Height:______Weight: ______

Occupation:______Currently working? Y o N o

Referring Physician:______Primary Physician:______

Last appointment with Physician:______Next appointment: ______

I have a history of (please check all that apply):

o Arthritis / o Asthma / o Back injury / o Bowel/Bladder issues / o Cancer
o Diabetes / o Dizziness / o Fractures / o Frequent falls / o Headaches
o Heart trouble / o High blood pressure / o Night sweats / o Osteoporosis / o Pacemaker
o Poor circulation / o Severe pain at night / o Smoking/Tobacco use / o Stroke / o Thyroid problems
o Other: ______

Please indicate the medications that you are presently taking or have taken recently:

o Anti-inflammatory / o Blood pressure / o Blood thinner / o Heart medication
o Insulin / o Muscle relaxant / o Painkiller / o Steroid (cortisone)
o Other: ______

Date of injury:______How did the injury occur? ______

______

What surgery/ies have you undergone?:______

Have you had any of the following tests? o None o X-ray o MRI o CAT o EMG o Other: ______

Have you had treatment for this present problem? Y o N o If yes, what? ______

______

Have you had any hospitalization(s) within the past year? Y o N o If yes, what? ______

Before the present pain/problem, what exercise(s) were you doing? ______

What activities are you having difficulty doing now? ______

Are you currently receiving physical therapy or home health treatments? Y o N o If yes, since when? ______

What are your goals for physical therapy? ______

Which of the following best describes your symptoms?

o Burning / o Constant / o Dull / o Intermittent
o Numbness / o Pins and needles / o Sharp / o Other:______

Please mark activities with + for aggravating pain and – for eases pain:

___ Bending backward / ___Bending forward / ___ Cough/Sneeze / ___ Getting up or down
___ Lying down / ___ Sitting / ___ Standing / ___ Walking
Other:______

Please place a mark on the line below to indicate the intensity of your pain.

0 –––––––––––––––––––––––– 5 ––––––––––––––––––––––––– 10

No pain As bad as it can be

Authorization for Treatment:

I authorize the physical therapist of Steamboat Physical Therapy

to administer such treatment as is prescribed and considered therapeutically

necessary based on the findings during the course of treatment.

The information provided is accurate to the best of my knowledge.

Signature: ______Date: ______