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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
MEDICAL HISTORY Patient Name:_________________________________________________ Age:_________ Height:_________ Weight: ________ Occupation:_____________________________________________________________________ Currently working? Y N Referring Physician:______________________________________ Primary Physician:__________________________________ Last appointment with Physician:______________________________ Next appointment: ________________________________ I have a history of (please check all that apply): Arthritis Asthma Back injury Bowel/Bladder issues Cancer Diabetes Dizziness Fractures Frequent falls Headaches Heart trouble High blood pressure Night sweats Osteoporosis Pacemaker Smoking/Tobacco use Stroke Poor circulation Severe pain at night Thyroid problems Other: __________________________________________________________________________________________ Please indicate the medications that you are presently taking or have taken recently: Anti-inflammatory Blood pressure Blood thinner Insulin Muscle relaxant Painkiller Heart medication Steroid (cortisone) Other: _______________________________________________________________________________________________ Date of injury:____________________ How did the injury occur? ___________________________________________________ _______________________________________________________________________________________________ What surgery/ies have you undergone?:_________________________________________________________________________ Have you had any of the following tests? None X-ray MRI CAT EMG Other: _________________________ Have you had treatment for this present problem? Y N If yes, what? _____________________________________________ _______________________________________________________________________________________________ Have you had any hospitalization(s) within the past year? Y N If yes, what? ______________________________________ Before the present pain/problem, what exercise(s) were you doing? __________________________________________________ _______________________________________________________________________________________________ What activities are you having difficulty doing now? ______________________________________________________________ Are you currently receiving physical therapy or home health treatments? Y N If yes, since when? _____________________ What are your goals for physical therapy? _______________________________________________________________________ Which of the following best describes your symptoms? Burning Constant Dull Numbness Pins and needles Sharp Intermittent Other:_____________________________ Please mark activities with + for aggravating pain and – for eases pain: ___ Bending backward ___Bending forward ___ Cough/Sneeze ___ Getting up or down ___ Lying down ___ Sitting ___ Standing ___ Walking Other:________________________________________________________________________________________________ Please place a mark on the line below to indicate the intensity of your pain. 0 –––––––––––––––––––––––– 5 ––––––––––––––––––––––––– 10 No pain As bad as it can be Authorization for Treatment: I authorize the physical therapist of Steamboat Physical Therapy to administer such treatment as is prescribed and considered therapeutically necessary based on the findings during the course of treatment. The information provided is accurate to the best of my knowledge. Signature: _____________________________ Date: ______________ Mark the body images using the symbols below: Moderate pain…… x Severe pain……… * Shooting or stabbing pain……. Numbness or tingling …………. o