Download Medical History - Steamboat Physical Therapy

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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
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