Health History Form ALLERGIES Are You Latex-Sensitive? Y N List Any Medication(S) You Are

Health History Form Hello and thank you for choosing Fusion Physical Therapy as the provider for your current healthcare need(s)! We look forward to working with you to help make your day a little easier! To ensure you receive a complete and thorough evaluation, please provide us with your important background information on the following form. If you do not understand a question, leave it blank and your therapist will assist you. Name:_______________________________________ Age: ______ Gender: _______ Occupation:Patient ___________________________________________________________ Characteristics Leisure Activities: ______________________________________________________ ALLERGIES Are you latex-sensitive? Y N List any medication(s) you are allergic to: ___________________________________ _____________________________________________________________________ List any other allergies we should know about:_______________________________ Please check (√) any of the following providers whose care you are under: ___Current medical Physicians doctor & ___ osteopath ___ dentist ___ psychiatrist ___ psychologist Non-physician providers ___ physical therapist ___ chiropractor ___ other: __________________________ Date of your last physical examination: ______________________ Has anyone in your immediate family (parents, brothers, sisters) ever been treated for any of the following? Y NRelevant Alcoholism Family History (chemical dependence) Y N High blood pressure Y N Cancer Y N Inflammatory arthritis Y N Depression Y N Kidney disease Y N Diabetes Y N Stroke Y N Heart Disease 1 | P a g e Health History Form Have you EVER been diagnosed as having any of the following conditions? Y N Arthritic conditions. If Y, what kind: _______________________________ Y N Asthma Y N Blood Clots Y N Cancer. If Y, what kind: _________________________________________ Y N Chemical dependence (e.g. alcoholism) Y N Circulation problems Y N Depression Y N Diabetes Y N Heart problems. If Y, what kind: __________________________________ Y N Hepatitis Y N High blood pressure Y N Kidney disease. If Y, what kind: ___________________________________ Y N Multiple Sclerosis Y N Osteoporosis Y N Stomach ulcers Y N Stroke Y N Thyroid problems. If Y, what kind: _________________________________ Y N Tuberculosis Y N Other condition(s): _____________________________________________ DATE REASON SURGERIES &/or HOSPITALIZATIONS ________ ______________________________________________________________ ________ ______________________________________________________________ ________ ______________________________________________________________ 2 | P a g e Health History Form General Health Screening: o Are you currently pregnant? Y N NA o During the past month have you been feeling down, depressed, or hopeless? Y N o During the past month have you been bothered by having little interest or pleasure in doing things? Y N o Do you ever feel unsafe at home or has anyone hit you or tried to injure you in any way? Y N o Have you ever been threatened, hurt, or made to feel afraid or humiliated by your partner or someone close to you? Y N o On average, how many days per week do you engage in moderate-to- strenuous exercise (like a brisk walk)? _________ days. o On average, how many minutes do you exercise at this level? ______ minutes. o How much sleep do you typically get? _______ hours per night. o Do you feel well rested when you wake up? ________________________ o Is your current condition impacting your sleep? Y N If Y, how so? __________________________________________________ o How would you rate your sleep quality? Good Fair Poor o Does being sleepy during the day interfere with your daily function? o Do you have difficulty falling asleep? Y N o Do you have difficulty returning to sleep if you wake up in the night? Y N o Do you have difficulty with waking up too early? Y N o Do you snore loudly or frequently? Y N o Has anyone observed you stop breathing while you sleep? Y N o When you try to relax in the evening or sleep at night, do you ever have unpleasant, restless feelings in your legs that can be relieved by walking or movement? Y N o How many caffeinated beverages (coffee or other) do you drink per day? ____ o Do you smoke? Y N. If Y, how many packs per day? ______ For how many years? _______. If you quit, when? _______________ o How many days/week do you drink alcohol? _______. If 1 drink = 1 beer3 | P or a g1 e glass of wine, how many drinks will you typically have at one sitting? _______ Health History Form General Health Screening (cont’d): Please select your most accurate response to each of the following questions: o Have you experienced a decline in your food intake over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties? □ severe decline □ moderate decline □ no decline o Have you experienced weight loss over the past 3 months? □ don’t know □ lost more than 6 pounds □ lost 2-6 pounds □ no weight loss o How mobile have you been over the past 3 months? □ chair / bed-bound □ can get in out of chair/bed, don’t go out □ can go out o Have you suffered psychological stress or acute disease in the past 3 months? □ yes □ no o Have you experienced problems with depression, dementia or any other psychological problems over the past 3 months? □ severe problems □ mild problems □ no problems Would you be interested in having a future discussion about your overall health with your therapist? □ yes □ ask me again later □no Have you been experiencing any NEW, UNUSUAL or ATYPICAL symptoms recently? Y N weight loss/gain Y N nausea/vomiting Y N dizzy/lightheaded Y N fatigue Y N fever/chills/sweats Y N weakness Y N numb/tingling Y N tremors Y N seizures Y N double vision Y N loss of vision Y N eye redness Y N skin rash Y N problems sleeping Y N sexual difficulties Y N night sweats Y N hearing problems Y N recent fall down Y N joint/muscle swelling Y N easy bruising Y N excess bleeding Y N difficulty breathing Y N regular cough Y N arm/leg swelling Y N heart racing Y N difficulty swallowing Y N heartburn Y N constipation/diarrhea Y N problems with bladder &/or bowel control4 | P a g e Health History Form Medication List Please complete our “Medication, Supplements & Remedies” form or, if you have your own form, please provide so we can make a copy. BODY DIAGRAM Please mark any area(s) of your body in which you are having ongoing symptoms. Please use 1-2 words to describe each symptom you are experiencing (eg. “sharp pain,” “dull pain,” “numbness,” “tingling,” “pins & needles,” etc. 5 | P a g e .

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