Medical History Form

Medical History Form
Do you have now or have you ever had any of the following conditions? Check only those that apply.
Cardiovascular

High Blood PressureStrokeChest PainHeart AttackDefribrilatorPacemakerMitral Vlave ProlapseAbnormal EKG/Stress TestTaking Anticoagulants
Neurologic

Seizures/FaintingDementiaParkinson'sOther
Pulmonary

COPD or EmphysemaAsthmaShortness of BreatheUse of OxygenTobacco Use
Musculoskeletal

Pain in JointsSwelling in JointsArtificial Joint(s)OsteoarthritisRheumatoid ArthritisScoliosisOsteopenia/Osteoporosis
Other Systemic

CancerDiabetes: Type I/IIThyroid AbnormalityBladder/Bowel ProblemsBleeding DisorderHistory of HIVHistory of HepatitisPregnancy (or trying?)Dizziness/VertigoWeight Loss/GainFalls/Near FallsOther
Psychiatric

DepressionAnxietyOther
Is there anything else you would like your therapist to know?

YesNo
If yes, please explain.
Do you have any allergies?

YesNo
Adverse reactions to medications?
List all medications you are currently taking (include OTC, herbals, supplements, vitamins, or attach list):
Please list any surgical procedures you have had (and dates)
Patient Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

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