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LT Physical Therapy PC Patient Medical and Physical History Questionnaire The purpose of this questionnaire is to identify medical complication, and common functional activities that give you difficulty or discomfort. This will help to establish medical necessity of treatment as well as help set functional goals. Along side each of the physical activities listed below, place a check next to any of the reasons that apply. Check as many reasons that are appropriate. Abnormal Posture Lying in bed Allergies Rolling over in bed Anemia Sitting-up from bed Angina or Chest Pain Sitting in chair Arthritis or pain in a joint Standing-up from chair Asthma Getting down on floor Cancer Getting up from floor Chronic Bronchitis Squatting or kneeling Circulatory Problems Driving car Dementias Getting in & out of car Depression Balancing Diabetes Mellitus (DM) Standing Difficulty Walking Discomfort in Middle or Lower Back or Radiating to the Legs Walking Jogging Emphysema Running Fracture Jumping Headaches Heart Disease (heart attack, abnormal rhythm, or congestive heart failure) Climbing stairs Hepatitis Hypertension (High Blood Pressure) Climbing ladder Bending Twisting or Turning Kidney Disease Nervous or Musculoskeletal Symptoms Reaching with arm(s) Obesity Pushing Reaching with leg(s) Open Skin Sores Pulling Osteoporosis Lifting overhead Pacemaker Lifting around waist height Persistent Mental Disorders Lifting from floor Pneumonia Carrying Polio Throwing Rheumatic/Scarlet Fever Rheumatoid Arthritis or other condition affecting multiple joints Gripping objects Working with hands & fingers Shortness of Breath Others: Please List Below Stomach Problems Stroke Urinary Tract Infection Vestibular (Inner Ear) Disorders Other Not Listed Other Balance PHYSICAL Activities List Fatigue DATE OF ONSET AND CURRENT STATUS Pain MEDICAL Problems List Weakness Reason you are having difficulty Please circle your medical problem and describe the status Motion Patient Name:_____________________________________ Patient / Client Medical and Physical History (Continued) Patient Name:_________________________________________ Please describe your current complaint and reason(s) for visiting LTPT including date of onset of injury or pain:_________________________________________________________________________________ ____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ What exercises or sports have you or do you participate in? __________________________________ __________________________________________________________________________________ What do you hope to achieve as a result of your course of physical therapy or training with us? __________________________________________________________________________________ Please list your orthopedic or relevant surgical history: ___________________________________ __________________________________ ____________________________________ __________________________________ Please list your present medications below: ____________________________________ ________________________________________ ____________________________________ ________________________________________ Special tests performed (e.g. X-ray, CT Scan, MRI): ________________________________________ Date(s) and Result (s): __________________________________________________________ Have you been discharged from a hospital or skilled nursing facility in the last 30 days? Yes / No If yes, date of discharge__________, name of hospital or skilled nursing facility ______________________________ Have you had any adverse reactions to past physical therapy? Yes / No If yes, please explain. _______ ____________________________________________________________________________________ Have you received Physical Therapy treatment for this same problem this calendar year? Yes / No If yes, when was your treatment? Start Date:______________ End Date:_______________ How many treatments did you receive?_____ Was the treatment successful?______________________ Signature: ____________________________________ Date:_____________________
