MEDICAL HISTORY FORM
Belle Mead Physical Therapy
Name
First Name
Last Name
Gender:
Male
Female
Other
Present health concern (which brought you here today):
Date of onset:
/
Month
/
Day
Year
Date
Past Injuries (please explain):
Past Rehabilitation (please explain):
Medications: Prescription and non-prescription medicine, vitamins, home remedies and herbs
Rows
Medication
Dose
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Surgical History: Please provide a list of significant surgeries and dates
Rows
Surgery
Date
1.
2.
3.
4.
Allergies: Please list all allergic reactions to any medication/food/other
Rows
Allergy
Reaction
1.
2.
3.
Personal Medical History: Please indicate if you have had any of the listed medical problems
Anemia
Arthritis
Diabetes Type 1
Diabetes Type 2
Epilepsy
Eczema
Hepatitis A
Hepatitis B
Hepatitis C
Asthma
Bleeding Disorder
High Cholesterol
High Blood Pressure
Heart Attack(s)
Kidney Disease
Migraine Headahes
Osteoporosis/Osteopenia
Osteoarthritis
Coagulation (bleeding disorder such as DVT)
Psoriasis
Rheumatoid Arthritis
Stroke
Staph Infections/MRSA
Tuberculosis
Problems with vision
Other
Have you ever been diagnosed with congenital heart disease?
Yes
No
If yes, specify type:
Have you ever been diagnosed with cancer?
Yes
No
If yes, specify type:
Have you ever been diagnosed with a heart condition?
Yes
No
If yes, specify type:
Have you ever been diagnosed with a thyroid condition?
Yes
No
If yes, specify type:
Height:
Weight:
Have you been given a flu shot?
Yes
No
Date of flu shot:
/
Month
/
Day
Year
Date
If no, why not?
Falls Risk Assessment: List any falls in the past year and any injuries due to fall
Additional Information: Please list any information that we should know that was not listed above
Print Name:
Signature
Date:
/
Month
/
Day
Year
Date
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