Medical History Questionnaire
Name
*
First Name
Last Name
Reason for referral to Physical Therapy:
*
What specific activities would you like to return to:
*
Date of injury or onset of problem:
*
/
Month
/
Day
Year
Date
Surgery date (if applicable):
/
Month
/
Day
Year
Date
How injury occurred:
*
On a scale of 0-10 how would you rate the pain currently?
*
0
1
2
3
4
5
6
7
8
9
10
No Pain
Worst Pain Imaginable
0 is No Pain, 10 is Worst Pain Imaginable
On a scale of 0-10 how would you rate the pain at its best?
*
0
1
2
3
4
5
6
7
8
9
10
No Pain
Worst Pain Imaginable
0 is No Pain, 10 is Worst Pain Imaginable
On a scale of 0-10 how would you rate the pain at its worst?
*
0
1
2
3
4
5
6
7
8
9
10
No Pain
Worst Pain Imaginable
0 is No Pain, 10 is Worst Pain Imaginable
Medications: List them below or give secretary a copy of Medication List. If not on any medications, please write "none" below.
*
Past Medical History: List any previous surgeries &/or injuries with dates if possible:
*
Have you ever been diagnosed as having any of the following conditions (Please check all of those that apply):
*
Pacemaker
High Blood Pressure (Hypertension)
Heart Problems
Diabetes
Circulatory Problems
Stroke
Osteoporosis
Kidney Disease
Seizures
Bowel Incontinence
Bladder Incontinence
Visual Impairment
Hearing Impairment
History of Falls
Vertigo
Psoriatic Athritis or Rheumatoid Arthritis
Osteoarthritis
Smoker
Drinker
Cancer
Pacemaker
Allergies
COPD
Asthma
Fibromyalgia
Thyroid Problems
HIV/AIDS
None of the Above
Other
Do you Smoke?
*
Yes
No
How many packs per day?
Do you drink alcohol?
*
Yes
No
How many drinks per week?
Are you currently pregnant?
*
Yes
No
N/A
Other information you feel may be important:
*
Is this a work-related injury?
*
Yes
No
Is this an auto-related injury?
*
Yes
No
If yes, what is the date of the injury/accident? Put "NA" if not a work/auto claim.
*
What is the name of the insurance company that has your claim? Put "NA" if not a work/auto claim.
*
What is your claim number? Put "NA" if not a work/auto claim.
*
What is the name and contact info (email, phone, fax) for your adjuster? Put "NA" if not a work/auto claim.
*
Today's Date
*
/
Month
/
Day
Year
Date
Patient Signature
*
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