Present/Past History: (Check if you ever had) Arthritis/swollen joints GoutAsthma, Bronchitis, or Emphysema High Blood PressureAngina, Coronary Heart Disease Heart Attack or SurgeryAnemia Infectious Diseases (i.e. ActiveTuberculosis)Bowel/Bladder Problems OsteoporosisBreathing difficulties/Shortness of breath PacemakerBlood Clot/Emboli Psychological/Emotional ProblemsCancer or Chemotherapy/Radiation Problems SleepingDiabetes Stroke/TIAEpilepsy/Seizures Thyroid Problems Pain level: 0 - No pain ever1 -2 - Mild pain3 -4 -5 - Moderate pain6 -7 -8 - Severe pain9 -10 - Worst pain Please check if you are taking any of the following medications: Anti-inflammatoryMuscle RelaxersPain MedicationsOther List names of medications: Do you have any allergies? YesNo If yes, please list: Have you had any surgeries? YesNo If yes, please list: Do you smoke? YesNo Are you aware of your diagnosis? YesNo Are you pregnant? YesNo What is your main problem/complaint? Estimated date of injury: What are your goals/expectations for physical therapy? Please check if you have had any of the following treatments or seen any of the following professionals to address your condition: Physical TherapyOccupational TherapyMassageChiropractorMRIX-RaysCT ScanEMG/NCVNeurologistOrthopedistGeneral PractitionerPodiatristMyelogramOther If other, please list: Are you currently working? Full TimePart TimeModified DutyNot workingRetired Full name: Email: Signature Date:
