Patient Questionnaire/Medical History Form

Under Medicare and the Maryland practice act we are required to obtain a complete medical history on all patients. This information is protected under HIPAA laws. Please answer all questions to the best of your ability.

 M F R L
 Home Auto Work Sports Other
 Y N
 Y N Y N
 No treatment received yet
 Physical Therapy Chiropractic Care Pain Management Mechanical Traction Massage Injections Aquatic Therapy Brace/Tape Surgical Intervention Personal Training Athletic Training
Other

Have any diagnostic tests been performed for this problem?:

 X-rays Bone Scan Doppler/Ultrasound MRI EMG CTScan Blood work
Other
 YES NO
 YES NO

Please mark an (X) where you hurt:

 getting worse improving the same
 sharp dull aching sore throbbing cramping burning shooting stabbing squeezing constant intermittent

Please rate your pain on 0-10 scale (0 is no pain, 10 is the worst pain you can imagine):

 0 1 2 3 4 5 6 7 8 9 10
 0 1 2 3 4 5 6 7 8 9 10
 0 1 2 3 4 5 6 7 8 9 10
 YES NO

 YES NO
 YES NO
 YES NO
 Cane Walker Crutches Wheelchair
 Excellent Very Good Good Fair Poor

Please circle yes or no if you have or have had any of the following conditions:


 YES NO

 YES NO

 YES NO
 YES NO

 YES NO
 YES NO


 YES NO

 YES NO
 YES NO

 YES NO
 YES NO
 YES NO
 YES NO

 YES NO
 YES NO
 YES NO
 YES NO
 YES NO
 YES NO

 YES NO
 YES NO

 YES NO

 YES NO
 YES NO

 YES NO
 YES NO
 YES NO

 YES NO
 YES NO

 YES NO
 YES NO
 YES NO

 YES NO
 YES NO
 YES NO

Please circle yes or no if you have or have had any of the following conditions:

 YES NO
 YES NO
 YES NO
 YES NO
 YES NO
 YES NO
 YES NO
 YES NO
 YES NO
 YES NO
 YES NO
 YES NO
 YES NO
 YES NO
 YES NO
 YES NO
 YES NO
 YES NO
 YES NO
 YES NO
 YES NO
 YES NO
 YES NO
 YES NO
 Glasses Contacts Dentures Pacemaker Metal Implant Hearing Aides

*List all medications/supplements/vitamins/OTC (over the counter) you currently take including dosage and frequency. This MUST be completed before your evaluation:

To the best of my ability, I have given and included all pertinent medical information.

Medical history reviewed by physical therapist and used in determining the plan of care.