Microsoft word - pt demographic and medical history forms 10.1

Patient Information & Release
(Please fill out the following forms as completely as possible):
Did you hear about our program from a Past Patient? If yes, please list the person’s name: ____________________________________________

DEMOGRAPHIC INFORMATION:
Name: __________________________________________________________________________________________________________________________________________

Address: ________________________________________________________________________________________________________________________________________
City: _____________________________________________________________ State :_____________________________ Zip Code: __________________________________
Home Phone: ___(_______)____________________________________________ Work Phone: ____(_______)_____________________________________________________
E-mail: ________________________________________ Employer: __________________________________; Type of Work/Job Title: ______________________________
Date of Birth ______/_______/_______ Gender: Male
Weight (lbs): ________ Height: ________ Marital Status (Please circle): Single / Married
Name and phone number of relative (not living with you) to contact in case of an emergency: ____________________________________________________________________
Do you use or consume any of the following:
Tobacco Product(s):
Type: ________________________________________________________
Alcohol:
Type: ________________________________________________________
Illicit Drugs: Type(s):
Type: ________________________________________________________
Caffeinated Beverage(s):
Type: ________________________________________________________


Is your condition related to: Workers’ Compensation:
________________________________________ If applicable, please list the name, address, phone and fax number of your Workers’ Compensation or Auto Negligence attorney or firm: _______________________________________________________________________________________________________________________________________________ (Name) REVIEWED WITH PATIENT: _______ Date: _______ Please list the approximate date of your injury OR the most recent date in which your condition started bothering you: ________________
NATURE OF INJURY OR HOW DID IT START? ______________________________ or NO CLEAR REASON
FOR THIS EPISODE,
FOR THIS EPISODE,
FOR THIS EPISODE,
I have consulted with:
I have had the following diagnostic tests:
I have had the following treatments:
Other:
None of the Above
Other:
None of the Above
SYMPTOM BEHAVIOR: Please answer the following in relationship to how your symptoms are behaving:
WORST TIME OF DAY: MORNING AFTERNOON EVENING UNUSUAL BUCKLING OF KNEES? Yes No
MAXIMUM TIME SITTING: ___________________ MINUTES HOURS MAXIMUM TIME STANDING: _________________ MINUTES HOURS UNUSUAL TRIPPING ON TOES? Yes No
UNUSUAL DIZZINESS? Yes No
UNUSUAL LIGHTHEADEDNESS? Yes No
REVIEWED WITH PATIENT: _______ Date: _______ PLEASE ANSWER THE FOLLOWING IN REGARD TO YOUR MEDICAL HISTORY:
Do you have any of the following medical conditions: (please circle the appropriate answer and elaborate as needed)
CARDIAC OR HEART PROBLEMS?
NO YES ______________________________________________________________________________________________

HIGH BLOOD PRESSURE? NO YES ______________________________________________________________________________________________
HISTORY OF HEART ATTACK? NO YES ______________________________________________________________________________________________
HISTORY CHEST PAIN(S)? NO YES _____________________________________________________________________________________________
HISTORY OF BLOOD CLOT? NO YES _____________________________________________________________________________________________
LUNG OR BREATHING PROBLEMS? NO YES ______________________________________________________________________________________________
ASTHMA? NO YES ______________________________________________________________________________________________
HISTORY OF CANCER? WHERE? NO YES ______________________________________________________________________________________________
HISTORY OF FRACTURE? WHERE? NO YES ______________________________________________________________________________________________
SPINE INFECTION? WHEN? NO YES ______________________________________________________________________________________________
DIABETES? NO YES ______________________________________________________________________________________________
HIGH CHOLESTEROL? NO YES ______________________________________________________________________________________________
ARTHRITIS? NO YES ______________________________________________________________________________________________
OSTEOPOROSIS? NO YES ______________________________________________________________________________________________
BONE DISEASE? NO YES ______________________________________________________________________________________________
HEADACHES/MIGRAINES? NO YES ______________________________________________________________________________________________
HISTORY OF SEIZURES? NO YES ______________________________________________________________________________________________
UNUSUAL WEIGHT CHANGE? NO YES ______________________________________________________________________________________________


Females – Are you currently or do you think you might be pregnant?
REVIEWED WITH PATIENT: _______ Date: _______ PAST SURGICAL HISTORY: Please CIRCLE all that apply; include date(s):
Other:
None of the Above:
PLEASE COMPLETE THE FOLLOWING INFORMATION AS COMPLETELY AS POSSIBLE:
Medications: Please circle all medications you are currently taking OR provide a separate list:
Other:
None of the Above

Allergies/Sensitivities:
Other:
None of the Above
REVIEWED WITH PATIENT: _______ Date: _______ Do you have any other medical conditions not previously mentioned?
No If yes, please explain: _____________________________________________ PATIENT PHYSICIAN INFORMATION
Please note to which physician you would like us to send your notes by placing a (*) in front of his or her name:
FAMILY PHYSICIAN:
If applicable, please complete the following:
Physician Name: ______________________________________ Office Number: _____________________ Fax Number: ___________________________
Address: ______________________________ City: ____________________ State: _______________________ Zip Code: __________________________
CARDIOLOGIST:
If applicable, please complete the following:
Physician Name: ______________________________________ Office Number: _____________________ Fax Number: ___________________________
Address: ______________________________ City: ____________________ State: _______________________ Zip Code: __________________________
OTHER SPECIALIST:
If applicable, please complete the following:
Physician Name: ______________________________________ Office Number: _____________________ Fax Number: ___________________________
Address: ______________________________ City: ____________________ State: _______________________ Zip Code: __________________________

OTHER SPECIALIST:
If applicable, please complete the following:
Physician Name: ______________________________________ Office Number: _____________________ Fax Number: ___________________________
Address: ______________________________ City: ____________________ State: _______________________ Zip Code: __________________________
REVIEWED WITH PATIENT: _______ Date: _______

Source: http://www.dynamicrehab.com/pdf/PT_Medical_History_Forms.pdf