Medical History Questionnaire
Name
*
First Name
Last Name
Reason for referral to Physical Therapy:
*
Primary goal to achieve or activities to return to with Physical Therapy:
*
The following questions are an insurance requirement. Thank you for answering each question. In the last 2 weeks, how often have you been bothered by any of the following problems:
*
Not at all
Several days
More than half of days
Nearly every day
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching TV
Moving or speaking so slowly that other people could have noticed. Or being so fidgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead, or of hurting yourself
PHQ-9 Calculation
Have you been diagnosed with bipolar disorder?
Yes
No
Have you been diagnosed with depression?
Yes
No
Have you had two or more falls in the past year or any fall with injury in the past year
*
Yes
No
Are you currently pregnant or nursing?
*
Yes
No
N/A
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
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.
*
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
If you checked YES to Cancer, Allergies, Contagious Diseases, Smoker, or Drinker, please specify:
If you said yes to Diabetes, which type have you been diagnosed with?
Type 1
Type 2
Other
Other information you feel may be important:
*
Today's Date
*
/
Month
/
Day
Year
Date
Patient Signature
*
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