Medical History Questionnaire


Name:

Gender:

Age:

Smoker:

(If yes, how many packs per day?)

Pregnant:

(Due Date)

Occupation:

What do you do to stay active during the week? How often?
 

Are you currently taking any medications/supplements?


If yes, please list:

Have you had an x-ray, MRI, or other imaging study related to your current symptoms?


If yes, please list test and date.

Past Medical History: Please check each condition that you have been told you have (or had).







Any other? (If yes, please explain.) 


Please list any previous surgeries, medical procedures, and/or hospitalizations with dates:

Do you take blood thinners?

Are you allergic to latex?

Other Allergies:

Currently I am experiencing: (check all that apply to your current symptoms)







In the past month, have you often been bothered by feeling down, depressed, or hopeless?

In the past month, have you often been bothered by little interest or pleasure in doing things?

Current Symptoms:

Where are you currently having symptoms? What brought you in to Physical Therapy?

What date (approximately) did your present symptoms start?

How did it start? (gradually, suddenly, injury)

My symptoms are currently:

Have you ever had this problem before?

Have you already received treatment for this problem?

 

If so, how was this problem treated and was it successful?

Does your problem prevent you from getting a full night's sleep?

 

Please answer the questions below based on the complaints for which you are primarily seeking treatment. 

Do you have increased pain with activity?

Identify up to 3 different important activities that you are unable to do, having difficulty with, or that increases your symptoms.

1.
2.
3.

What makes your symptoms better?




Using the scale above, which number represents your current level of pain?





Using the scale above, which number represents your current level of activity?

What is your personal goal for therapy?

How did you hear about us?

Leave this empty:

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Signature Certificate
Document name: Medical History Questionnaire
lock iconUnique Document ID: bdadccf358aeffcb9eb6b91d2bc9e53db5c0c916
Timestamp Audit
January 27, 2020 2:45 pm AKSTMedical History Questionnaire Uploaded by Jaimee Watson - jaimee@ohwpt.com IP 206.223.197.206
June 8, 2020 3:32 pm AKSTNikki Brown - nikki@ohwpt.com added by Christopher Comstock - emily@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206
August 28, 2020 9:34 am AKSTNikki Brown - nikki@ohwpt.com added by Optimum Health and Wellness - emily@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206
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June 10, 2024 10:32 am AKSTMaKeylee Tolle - makeylee@ohwpt.com added by Jaimee Watson - jaimee@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206
June 10, 2024 10:36 am AKSTAnnie Morris - annie@ohwpt.com added by Jaimee Watson - jaimee@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206
June 10, 2024 10:36 am AKSTMaKeylee Tolle - makeylee@ohwpt.com added by Jaimee Watson - jaimee@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206
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