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Download Patient`s Name: - Absolute Physical Therapy
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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
