PHYSICAL THERAPY MEDICAL HISTORY
(Page 1 of 2)
Today’s Date: _____ / _____ /_____
Name: (First) ______(Middle Initial) _____ (Last) ______
Prescription Medications/Supplements: ______
Allergies: None Latex Adhesive Other:______
Major Injury History:______
Surgical History:______
______
_
Address: 15808 Mill Creek Blvd., Suite 120 Mill Creek, WA 98012
Phone: 425-298-4072 Fax: 425-298-4076
PHYSICAL THERAPY MEDICAL HISTORY
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Today’s Date: _____ / _____ /_____
(Check all that apply)
Anxiety
Arthritis
Broken Bones/Fractures
Cancer
Depression
Diabetes
Dizziness
Eye Problems
Head Injury
Heart Problems
High Blood Pressure
Kidney Problems
Liver Problems
Lung Problems
Multiple Sclerosis
Muscular Dystrophy
Osteoporosis
Parkinson’s disease
Seizures
Stroke
Varicose Veins
Vestibular:
Other:______
______
Address: 15808 Mill Creek Blvd., Suite 120 Mill Creek, WA 98012
Phone: 425-298-4072 Fax: 425-298-4076
PHYSICAL THERAPY MEDICAL HISTORY
(Page 2 of 2)
Exercise:
Step Mill; Treadmill; Elliptical; Stationary Bike Running Walking Weight Training
(How Often?) Hours/Week: ______Days/Week: ______
Activities for Recreation:
Hiking Soccer Basketball Tennis Racquetball Other: ______
(How Often?) Hours/Week: ______Days/Week: ______
Smoking: Yes No (If yes, how many packs/day?) _____
Alcohol Consumption: Yes No (If yes, how often?) _____
Address: 15808 Mill Creek Blvd., Suite 120 Mill Creek, WA 98012
Phone: 425-298-4072 Fax: 425-298-4076
PHYSICAL THERAPY MEDICAL HISTORY
(Page 2 of 2)
Address: 15808 Mill Creek Blvd., Suite 120 Mill Creek, WA 98012
Phone: 425-298-4072 Fax: 425-298-4076
PHYSICAL THERAPY MEDICAL HISTORY
(Page 2 of 2)
(Check all that apply)
Chest Pain
Coordination Problems
Decreased Range of Motion
Difficulty Concentrating
Difficulty Sleeping
Headaches
Hearing Problems
Loss of Balance
Pain at Night
Vertigo/Dizziness
Visual Problems
Weakness
Other: ______
Address: 15808 Mill Creek Blvd., Suite 120 Mill Creek, WA 98012
Phone: 425-298-4072 Fax: 425-298-4076
PHYSICAL THERAPY MEDICAL HISTORY
(Page 2 of 2)
Please mark your pain today with “X” on this scale:
No Pain Worst Possible Pain
Please indicate below where you are experiencing symptoms? (Use legend)
Address: 15808 Mill Creek Blvd., Suite 120 Mill Creek, WA 98012
Phone: 425-298-4072 Fax: 425-298-4076
PHYSICAL THERAPY MEDICAL HISTORY
(Page 2 of 2)
Address: 15808 Mill Creek Blvd., Suite 120 Mill Creek, WA 98012
Phone: 425-298-4072 Fax: 425-298-4076
PHYSICAL THERAPY MEDICAL HISTORY
(Page 2 of 2)
Address: 15808 Mill Creek Blvd., Suite 120 Mill Creek, WA 98012
Phone: 425-298-4072 Fax: 425-298-4076
PHYSICAL THERAPY MEDICAL HISTORY
(Page 2 of 2)
______Today’s Date:_____ / _____ /_____
Patient – age 18 or older Month Day Year
______Today’s Date:_____ / _____ /_____
Parent/Guardian – if patient is under age 18 Month Day Year
Address: 15808 Mill Creek Blvd., Suite 120 Mill Creek, WA 98012
Phone: 425-298-4072 Fax: 425-298-4076