Medical History Form
Date of Birth
Health Conditions (Please check any that you have or have had in the past)
Shortness of Breath
Blood Pressure abnormalities
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?
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.
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?
Have you had any musculoskeletal injuries in the past 12 months that caused you to modify your normal activities?
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?
Should be Empty: