Health History form

Health History Form

History of Present Condition

Last Name

What date did your symptoms begin?

Please describe your symptoms

Briefly describe how your injury occurred (if your condition is chronic or post-surgical please indicate)

Have you had similar symptoms in the past? yesno

On a scale of 1 (no pain) to 10 (worst pain ever felt) what is your pain level?

currently: at it's worst:

Have you had any previous treatments for this condition? (Eg. PT, chiropractic, meds, injections, massage, acupuncture)?

Does the pain wake you at night? yesno

Since the onset of your current symptoms have you had:
any difficulty with control of bowel or bladder functionfever/chillsany numbness in the genital or anal areasany dizziness or fainting attacksunexplained weight changenight pain/sweatsmalaise (vague feeling of bodily discomfort)problems with vision/hearing

What aggravates your symptoms?
(Eg. Sitting, standing, walking, lying, stairs, reaching, coughing, lifting...) List specific activities, if possible.

What relieves your symptoms?
(Eg. Rest, heat, ice, sitting, standing, walking, lying, meds…)

Past Medical History

Please list all current and past medical issues:
(Eg. Heart conditions, diabetes, musculoskeletal conditions, osteoporosis, high cholesterol, depression, anxiety, thyroid condition, cancer, infectious disease, rheumatoid arthritis…)

Have you had any diagnostic tests or imaging for this condition (Eg. X-ray, MRI, CT scan, EMG)? If so, please describe the test results:

Please list any over-the-counter or prescription medications you are taking:

Please list any past surgeries (include dates):

Describe any physical acitivies at work, recreational activities and/or your current exercise routine:

Do you have any specific goals that you want to accomplish during therapy? (Eg. pain relief, return to sports, strengthening)