Download Patient`s Name: - Absolute Physical Therapy

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Transcript
Absolute
Physical Therapy
 1365 Broadway, Bangor, ME 04401  (207) 942-2233  (207) 262-1130 fax
PATIENT HISTORY FORM
Patient’s Name:
Patient’s Email: ___________________ Date of Birth:
Thank you for providing the following important information to help us help you. Please let us know if you have any questions.
Describe your symptoms: ______________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
When and how did your symptoms begin?: __________________________________________________________________
Date of Surgery: _____________________________
Pain Levels (0-10): Average___________ Maximum ______________
What makes you worse: _______________________________________________________________________________
What makes you better: ________________________________________________________________________________
Previous treatment: ___________________________________________________________________________________
Please mark the diagram to show us your problem areas using
these symbols:
NT Numbness/Tingling
A Ache
B Burning
S Sharp
D Dull
Also number the order of importance (1, 2, etc.) next to each
area (#1 the most problematic).
INSTRUCTIONS: Put  in those boxes applicable to you and in the “yes” or “no” space. If lines are provided, write in your answer.
Have you ever had . . .
No
Yes
Pneumonia
Pleurisy
Have you ever had . . .
No
Yes
Have you ever had . . .
Osteoporosis
Osteopenia
Epilepsy
Any Broken Bones
Dislocations
Diabetes
Ever Been Unconscious
Cancer
 Nervous Breakdown  Depression
Fibromyalgia
 High  Low Blood Pressure
Surgery
 Neuritis  Neuralgia
 Bursitis  Sciatica  Back Pain
Headaches: □ Frequent □ Severe
Explain
Neck pain
Frequent  Colds  Sore Throat
Pregnancies
Meningitis
Frequent  Infections  Boils
Any Other Disease
Explain
How many:
 Rheumatic Fever  Heart Disease
 Arthritis  Rheumatism
Any  Bone  Joint Disease
Kidney Disease
Sexually Transmitted Disease
Pulmonary Disease
Any additional major illnesses, with date (if known):
Allergies
Medications
 Concussion  Head Injury
□ Chest Pain □ Angina Pectoris
Years:
No
Yes