Rivetus Rehabilitation Medical History Form

1
Name
First Name
Last Name
2
Physician Information
Who is your referring physician? Physician Name
Who is your primary care physician (if different than referring)? Physician Name
When was your last appointment? appointment date
When is your next appointment? appointment date
3
Please check all boxes that apply to your medical historyGENERAL
HEARING PROBLEMS
ANXIETY
VISION PROBLEMS
DEPRESSION
CANCER
DIABETES
INCONTINENCE
KIDNEY DISORDER/FAILURE
WOUNDS
SKIN CONDITION
NONE
Other
4
Please check all boxes that apply to your medical historyRESPIRATORY
ALLERGIES
SLEEP APNEA
ASTHMA
TUBERCULOSIS (TB)
COVID-19 INFECTION
BREATHING ISSUES
COPD
NONE
Other
5
Please check all boxes that apply to your medical historyCARDIAC & CIRCULATORY
HEART ATTACK
PACEMAKER/DEFIBRILLATOR
HEART FAILURE
ANEURYSM
ATRIAL FIBRILLATION (A-FIB)
DVT (BLOOD CLOT)
HIGH BLOOD PRESSURE
NONE
Other
6
Please check all boxes that apply to your medical historyNEUROLOGICAL
EPILEPSY
MULTIPLE SCLEROSIS (MS)
HEAD INJURY
PARKINSON'S DISEASE
HEADACHES
STROKE
NEUROPATHY
RHEUMATOID ARTHRITIS
NONE
Other
7
Please check all boxes that apply to your medical historyMUSCULOSKELETAL
OSTEOARTHRITIS
BACK PROBLEMS
OSTEOPOROSIS
NECK PROBLEMS
METAL IMPLANTS
NONE
Other
8
Vaccine Information
Flu Shot (recommended annually)
Pneumonia Vaccine
COVID-19 Initial Vaccine Series
COVID-19 Vaccine/Booster (recommended annually)
9
TB Symptom QuestionnairePlease place a check in the appropriate box. Do you currently have
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Persistent Cough (greater than 2 weeks duration)
Unexplained Weight Loss
Night Sweats
Bloody Sputum
Loss of Appetite
Fever
Weakness
Persistent Cough (greater than 2 weeks duration)
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
1 of 7
10
Pain
Do you have pain? If so, please describe where: location
How would you describe your pain? ex. sharp, achy, burning, etc.
What is the best your pain gets on a scale of 0-10? 0 is no pain, 10 is worst pain
What is the worst your pain gets on a scale of 0-10? 0 is no pain, 10 is worst pain
Do you take medications for pain? If so, please list medications and dosage. Pain Medication Name & Dosage
If you take medication for pain, is it effective?
11
Falls
Have you had any falls in the last year? Yes or No
If yes, how many? Number of falls
Do you worry about falling? Yes or No
12
Over the last two weeks, how often have you had little interest or pleasure in doing things?
Please Select
Please Select
a. Not at all
b. Several days
c. More than half the days
d. Nearly every day
13
Over the last two weeks, how often have you felt down, depressed, or hopeless?
Please Select
Please Select
a. Not at all
b. Several days
c. More than half the days
d. Nearly every day
14
Patient-Specific Functional ScalePlease list 3 important activities you are having difficulty with as a result of your current problem, then rate your current level of difficulty from 0-10 for each of those activities. 0 is unable to perform, 10 is able to perform at prior level
Activity you are unable to do or having difficulty with
Please Select
Please Select
0
1
2
3
4
5
6
7
8
9
10
0 is unable to perform, 10 is perform at prior level
Activity you are unable to do or having difficulty with
Please Select
Please Select
0
1
2
3
4
5
6
7
8
9
10
0 is unable to perform, 10 is perform at prior level
Activity you are unable to do or having difficulty with
Please Select
Please Select
0
1
2
3
4
5
6
7
8
9
10
0 is unable to perform, 10 is perform at prior level
15
Over the last two weeks, how often have you
Please Select
Please Select
a. Not at all
b. Several days
c. More than half the days
d. Nearly every day
had little interest or pleasure in doing things?
Please Select
Please Select
a. Not at all
b. Several days
c. More than half the days
d. Nearly every day
felt down, depressed, or hopeless?
16
Final Questions
Have you had any recent surgeries? If yes, please describe
Do you have any precautions? If yes, please describe
What are your goals for therapy? Please describe
Is there anything you want to add? Please describe
Should be Empty: