Medical History for Agility Physical Therapy

Medical History

Welcome to Agility Physical Therapy. Please answer the questions to the best of your ability. If unsure, leave blank. If you have a medication and / or a surgery list, please provide to the staff so it can be copied.
Patient Name*

First NameMiddle NameLast NameSuffix
Today's date*

MonthDayYear
Date
Current issues
What is your main problem?
When did it start?
How did it happen?
Have you had any testing done for this problem? If yes, what type of testing?

X-rayMRIEMGCT ScanUltrasoundMyelogramOther
Have you had any of the following done for this problem?
Please list date & type if applicable.
Surgery
Nerve block
Physical therapy
Brace
Injection
Massage therapy
Chiropractor
Orthotic / Inserts
Other
Do you have any of the following?

PainRadiating painNumbnessTinglingSwellingStiffnessClickingCatching / LockingPoppingGrindingInstability
What is your current level of pain?
On a scale from 0-10 with 0 being no pain and 10 being emergency room pain.
What is the worst level of pain?
On a scale from 0-10 with 0 being no pain and 10 being emergency room pain.
What activities make you feel worse?
What activities make you feel better?
What is your goal for therapy?
Who can we thank for referring you to our facility?
Medical History
Please select if you have or have had any of the following issues.

AIDS / HIVAnemiaArthritisAsthmaBack issuesBladder issuesBlood clotsCancerCrohns / IBSCirculationDepressionDiabetesEhler's DanlosEpilepsyFibromyalgiaGoutHeart issuesHypertensionKidney issuesLiver issuesLung issuesLupusMultiple sclerosisNeck issuesOsteopeniaOsteoporosisPacemakerPhlebitisPsychologicalRASkin issuesStomach ulcerStrokeThyroid issuesTuberculosisOther
Are you taking any medications?

YesNo
If yes, please list or provide us with a list.
Do you have any allergies?

YesNo
If yes, please list.
Have you had any previous surgeries?

YesNo
If yes, please list or provide us with a list.
Social History
What is your occupation?
Are you currently working? (Multiple selections allowed)

YesNoFull-timePart-timeFull-dutyRestricted Duty
Do you smoke?

YesNo
If yes, how many packs per day?
If yes, how many years have you smoked?
Do you currently participate in a sport or exercise program?

YesNo
If yes, please describe
If no, would you like to start an exercise program?

YesNo
Patient signature

Clear
Should be Empty:

Medical History

Current issues

Medical History

Social History