Musculoskeletal New Patient History
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Patients Name
Patient's Date of Birth
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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 & Needles
Burning
Stabbing/Sharp
Aching
Tightness
Shooting
Numbness/Tingling
Twisting
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 Scan
MRI
EMG
X-Rays
Injections
Surgery
Medical Illnesses (that you have been Diagnosed with: highlight those that apply)
Diabetes
Asthma
High Blood Pressure
Heart Attack
Sleep Disorders
Stroke
Stomach Ulcers
Cancer
Heart Murmur
HIV/AIDs
Hepatitis
Anemia
Seizures
Hyper/Hypo Thyroid
Osteoporosis
Deep Vein Thrombosis
Osteoarthritis or Rheumatoid Arthritis
Bowel or Bladder Incontinence
Broken Bones
Other
Injuries: (Include broken bones, concussion, motor vehicle accidents, falls etc
Surgeries: 1
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Surgeries: 2
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Surgeries: 3
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Family History of Medical Problems: (Highlight those that apply)
Arthritis
Back Problems
Heart Problems
Diabetes
Cancer
Other
Do you exercise?
Yes
No
What type of Exercise?
How often and how long?
Occupation
Hobbies/Interests
Therapist Signature
Patient Signature
Submit
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