"Medical Intake Form - Quality Physical Therapy"

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Medical Intake Form
Name:_______________________________________ Date of onset of symptoms:_________
List medications currently taking:________________________________________________
List any test(s) for this problem:__________________________________________________
If female, are you pregnant? Yes
No
Name of doctor who sent you to therapy:___________________________________________
Do you have any past or present history of:
YES
NO
(List, even if controlled with medication)
____
____
Heart disease, high blood pressure, angina, pacemaker?
Respiratory Problems, asthma, allergies, TB?
____
____
Diabetes (any type)?
____
____
Arthritis (diagnosed by MD)?
____
____
Bone disease(s)?
____
____
Skin Disorders, Eczema, Psoriasis, athlete’s foot?
____
____
Communicable diseases, hepatitis, TB?
____
____
History of cancer (any type)?
____
____
Any metal or artificial implants?
____
____
Any previous injuries to the same area?
____
____
Any previous surgeries?
____
____
Any history of seizures or epilepsy?
____
____
Do you have a latex allergy?
____
____
Please explain any YES answers._________________________________________________
In the diagram on the right, please mark the area(s) where your pain/symptom(s) are located using
the following symbols: X = Pain, /// = Pins & Needles, O = numbness, ^^^ =Shooting Pain
Please rate your pain right now on a scale of 0 – 10
With 0 being no pain and 10 being the worst pain
Imaginable:
0---1---2---3---4---5---6---7---8---9---10
What do you rate your pain at it’s lowest ?___/10
What do you rate your pain at it’s highest?___/10
Signature:______________________________________________Date__________________
Medical Intake Form
Name:_______________________________________ Date of onset of symptoms:_________
List medications currently taking:________________________________________________
List any test(s) for this problem:__________________________________________________
If female, are you pregnant? Yes
No
Name of doctor who sent you to therapy:___________________________________________
Do you have any past or present history of:
YES
NO
(List, even if controlled with medication)
____
____
Heart disease, high blood pressure, angina, pacemaker?
Respiratory Problems, asthma, allergies, TB?
____
____
Diabetes (any type)?
____
____
Arthritis (diagnosed by MD)?
____
____
Bone disease(s)?
____
____
Skin Disorders, Eczema, Psoriasis, athlete’s foot?
____
____
Communicable diseases, hepatitis, TB?
____
____
History of cancer (any type)?
____
____
Any metal or artificial implants?
____
____
Any previous injuries to the same area?
____
____
Any previous surgeries?
____
____
Any history of seizures or epilepsy?
____
____
Do you have a latex allergy?
____
____
Please explain any YES answers._________________________________________________
In the diagram on the right, please mark the area(s) where your pain/symptom(s) are located using
the following symbols: X = Pain, /// = Pins & Needles, O = numbness, ^^^ =Shooting Pain
Please rate your pain right now on a scale of 0 – 10
With 0 being no pain and 10 being the worst pain
Imaginable:
0---1---2---3---4---5---6---7---8---9---10
What do you rate your pain at it’s lowest ?___/10
What do you rate your pain at it’s highest?___/10
Signature:______________________________________________Date__________________