Musculoskeletal New Patient History

Musculoskeletal New Patient History
Date

MonthDayYear
Date
Patients Name
Patient's Date of Birth

MonthDayYear
Date
Patients Age
Chief Complaint
When and how did the problem occur?
Was this a result of an acute injury or accident?
Problem Diagram: (Using the diagram below, please describe where you are experiencing difficulty)
If you have pain please describe the pain sensation. (Highlight those that apply)

Pins & NeedlesBurningStabbing/SharpAchingTightnessShootingNumbness/TinglingTwisting
When during the day do you have your pain?
What makes your pain worse?
What makes your pain better?
What daily activities does this problem affect?
Have you received any special testing or procedures for this problem? (Highlight your issues below)

CT ScanMRIEMGX-RaysInjectionsSurgery
Medical Illnesses (that you have been Diagnosed with: highlight those that apply)

DiabetesAsthmaHigh Blood PressureHeart AttackSleep DisordersStrokeStomach UlcersCancerHeart MurmurHIV/AIDsHepatitisAnemiaSeizuresHyper/Hypo ThyroidOsteoporosisDeep Vein ThrombosisOsteoarthritis or Rheumatoid ArthritisBowel or Bladder IncontinenceBroken Bones
Other
Injuries: (Include broken bones, concussion, motor vehicle accidents, falls etc
Surgeries: 1
Date

MonthDayYear
Date
Surgeries: 2
Date

MonthDayYear
Date
Surgeries: 3
Date

MonthDayYear
Date
Family History of Medical Problems: (Highlight those that apply)

ArthritisBack ProblemsHeart ProblemsDiabetesCancerOther
Do you exercise?

YesNo
What type of Exercise?
How often and how long?
Occupation
Hobbies/Interests
Therapist Signature

Clear
Patient Signature

Clear
Should be Empty: