Medical History Form
Name
*
First Name
Last Name
Date of Birth
*
Today's Date
*
Gender Assigned at Birth
*
female
male
not specified
Gender Identity
*
female
male
transgender
non-binary
other
What is the primary concern or goals that you would like to have addressed?
Health History
Health Conditions (Please check any that you have or have had in the past)
*
Stress Fracture
Asthma
Scoliosis
Dizziness/Fainting
Shortness of Breath
Blood Pressure abnormalities
Diabetes
Seizures
Heart Conditions
Chronic Pain
I do not have any significant health issues.
Please list any other health conditions and/or provide information on current conditions.
Have you had any surgeries?
*
Yes
No
Please provide date (year and month) of surgeries and brief description.
Do you take any medications (prescription or over-the-counter)?
*
Yes, I currently take some medications regularly.
No, I am not currently taking any medications.
Please indicate if you use any of the following:
Caffeine
Alcohol
Nicotine products
Recreational drugs
Please describe dosage/quantity and frequency with which you use the above.
Do you take any vitamins or dietary supplements?
*
Yes, I currently take some vitamins or dietary supplements regularly.
No, I am not currently taking any vitamins or dietary supplements regularly.
Please list names, dosages, and frequency of all medications and vitamins/supplements.
Do you have a dietary restrictions or food intolerances (vegan, vegetarian, gluten-free)? If "yes" please describe.
*
Do you have allergies other than seasonal? If yes, please describe.
*
Do you have difficulty maintaining your current body weight?
*
Yes
No
Injury History
Have you had any musculoskeletal injuries in the past 12 months that caused you to modify your normal activities?
*
Yes
No
Were you seen by a healthcare practitioner? If yes, what type of healthcare provider (PT, Orthopedist, MD, Chiropractor, etc)?
What was the diagnosis or area(s) that were injured?
Have you had PT in the last 12 months? If yes, please list injured areas.
Please list any continuing concerns or problems due to injury or other pertinent history.
Physical Activity Participation
Please describe any sport, physical activities, or leisure activities that you regularly participate in.
How many hours/week are spent in participation?
Please list the name and phone numbers or practice of your primary care physician, orthopedist, and any other care providers that you are currently seeing.
Submit
Should be Empty: