Patient Medical History Form

PATIENT MEDICAL HISTORY FORM Name: ______Treating Physician: ______Primary Care Physician: ______Date of 1st Doctors Visit for this Injury:______Last Day Worked Due to this Injury (if applicable):______Date Returned to Work after Injury (if applicable):______Have you retained an attorney as a result of your injury? YES NO Referral Source: Surgeon Rehab MD Other:______Have you had Surgery for this Injury? YES NO Number of Surgeries:______Type of Surgery(ies):______

Are you currently taking any medications (prescription and/or over the counter medicines):

Anti-Inflammatories YES NO If YES, please specify:______Muscle Relaxers YES NO If YES, please specify:______Pain Medication YES NO If YES, please specify:______Other YES NO If YES, please specify:______

Have you had any of the following diagnostic, medical or rehabilitative services for this injury/episode?

YES NO YES NO Chiropractor ______General Practitioner ______EMG/NCV ______CT Scan ______Massage Therapy ______MRI ______Myelogram ______Neurologist ______Occupational Therapy______Orthopedist ______Physical Therapy ______Podiatrist ______Emergency Room ______X-Rays ______

Do you now or have you ever had any of the following?

YES NO YES NO

Asthma, Bronchitis, or Emphysema ______High Blood Pressure ______Anemia ______Shortness of Breath/Chest Pain ______Heart Attack or Surgery ______Diabetes ______Coronary Heart Disease or Angina ______Thyroid Trouble/Goiter ______Gout ______Cancer/chemotherapy/Radiation ______Dizziness or Fainting ______Weakness ______Emotional/Psychological Problems ______Infectious Diseases ______Hernia ______Bowel or Bladder Problems ______Numbness or Tingling ______Allergies ______Severe or Frequent Headaches ______Elbow/Hand Injury ______

Osteoporosis ______Vision or Hearing Difficulties ______

YES NO YES NO

Neck Injury/Surgery ______Stroke/TIA ______Sleeping Problems/Difficulties ______Back Injury/Surgery ______Blood Clot/Emboli ______Leg/Ankle/Foot Injury/Surgery ______Knee Injury/Surgery ______Epilepsy/Seizures ______Do you have a Pacemaker? ______Arthritis/Swollen Joints ______Varicose Veins ______Any Pins or Metal Implants? ______Are You Pregnant? ______Joint Replacement ______Weight Loss/Energy Loss ______Do You Smoke? ______

Please list any additional information that would assist us in providing care to you? ______

Are you aware of your diagnosis (what you are being treated for at our clinic)? Yes No

What are your expectations/goals? ______

By my signature below, I certify that the information I have provided above is complete, accurate and truthful to the best of my knowledge.

Patient/Legal Guardian Signature: ______Date: ______

Patient/Legal Guardian Name: ______

Therapist’s Signature:______Date: ______