RegistrationYour Medical History: Patient Information Name * First Name Last Name Date of Birth MM DD YYYY Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Emergency Contact Emergency Contact Name * Emergency Contact Phone * (###) ### #### Physician Physician Name * First Name Last Name Physician Phone Number * (###) ### #### Medical Information Please list any allergies Please list any medications you are currently taking: Please list any non-perscriptions you are currently taking: List the all conditions that are affecting treatment What is your chief Complaint? What are your goals from Physical Therapy?Text Area 5 When and how did this problem begin? What activities or positions make you feel better? What activities or positions make you feel worse? Is your condition getting better, worse or staying the same? What treatments have you received for this injury so far? Have you had any special tests such as x-rays, MRI or CT scans? Are you presently working? If so, what are the physical demands of your job? How active are you? One a scale from 1 to 10, with 10 being extremly active. What physical activities do you want to be able to do? Is there anything else you would like me to know? Please answer the following questions: Do your current problems interrupt your sleep? Yes No Do you have any vertigo or dizziness? Yes No Are you currently pregnant? Yes No ave you had any changes in bowel or bladder function? Yes No Do your symptoms change with coughing, sneezing or laughing? Yes No Do you have or have you had any type of cancer? Yes No Do you have osteoporosis? Yes No Do you have any changes in sensation (numbness, tingling)? Yes No Text Area 16 If yes, where? Do you have diabetes? Yes No Do you have any cardiac issues (high blood pressure, atrial fibrillation, etc)? Yes No Do you have increased fatigue? Yes No Do you have any shortness of breath or decrease in endurance? Yes No Do you have any bruising, blood clot or bleeding disorders? Yes No Do you have any recent visual changes (blurry vision, double vision)? Yes No Do you have a seizure disorder? Yes No Do you have depression or anxiety? Yes No Radio 16Have you ever had MRSA, C DIFF, Staph or other antibiotic resistant conditions? Yes No Do you have any skin issues (i.e.pressure ulcers)? Yes No Thank you for submitting your health history with me. I’ll review your comments and respond back within 24 hours.Thank you,Tami
