<p> Rushmore Physical Therapy, P. A. Women’s Health Past Medical History </p><p>Name: ______Age: _____ Today’s date: ______Next Dr appointment: ______Referring Physician: ______Primary Physician: ______Phone and fax: ______Phone and fax: ______Diagnosis: ______Date of onset or injury: ______</p><p>Please circle any of these conditions that apply to you. Cancer: Where: ______When:______Treatments: ______Breast Discharge/Disorder Uterus/Prolapse Ovary Issues Bladder Issues/Prolapse Bowel Issues/Prolapse Cysts/Fibroids Colitis/Polyps Constipation/Diarrhea Sexual Dysfunction Osteoporosis/osteopenia Sprains/Strains/Ligament Injury Back/Neck Injury Fractures/Dislocations Rheumatoid/Osteo arthritis Diabetes - Type I or II Heart Disease/Attacks High Blood Pressure Angina Pacemaker Metal or Breast Implants Asthma Emphysema/COPD Anemia/Bleeding disorders Hepatitis A, B, C Thyroid Issues Kidney Problems/Stones Liver Disease Gall Bladder Problems Hernia –inguinal or hiatal Ulcers –stomach or intestine Stomach/indigestion Nausea/vomiting Stroke/TIA Seizures/Epilepsy Migraines/Headache Head Injury Anxiety/Panic/Depression Mental Illness/Confusion Chronic Pain Addictions Multiple Sclerosis /Lupus Fibromyalgia/Other Parkinson’s Disease/ALS Paralysis HIV/AIDS Peripheral Vascular Disease Numbness/tingling in arms/legs Dizziness/Loss of Balance Other: ______Allergies: ______Do you smoke? Y/N How long? ______When did you quit? ______Please list medications/supplements you currently are taking: ______Have you had any of the following procedures, when and to what body part: Bone Scan: ______Last Mammogram:______Colonoscopy: ______X-Rays: ______CT Scan or MRI: ______EMG: ______Myelogram: ______Injections: ______Balloon Expulsion: ______Other: ______</p><p>Surgeries you had and when: Hysterectomy: ______Ovarian surgery/removal: ______Tubes tied/removed: ______Breast surgery: ______Pelvic floor reconstruction: ______Rectal reconstruction: ______Bladder: ______Uterus Reconstruction: ______WH – PMH pg.2</p><p>Other Surgeries: ______Cosmetic Surgery: ______</p><p>Please circle: Have you ever experienced a significant injury before? Y/N When: ______How: ______Have you ever received Physical Therapy for this or another issue? Where: ______When: ______</p><p>Please circle all treatments you have had or are presently receiving: Pain Relief Manual Therapies Exercise Other Hot/Cold Packs Massage Stretching Biofeedback Electric Stimulation Adjustments Strengthening Acupuncture TENS Chiropractic Stationary Bike Rheumatologist Ultrasound Mobilization Treadmill Orthopedist Mechanical Traction Manual Traction UBE Podiatrist Taping Pool therapy yoga Meditation Other: ______</p><p>Impact on lifestyle: My general health now is: excellent/ good/ fair/ poor. My current activity level is: sedentary/ active/ strenuous. Prior to injury, my activity level was: sedentary/ active/ strenuous.</p><p>Is there anything else we should know about you, your illness or injury that is not already covered: ______</p><p>I have answered the above questions accurately and to the best of my knowledge.</p><p>Patient Signature: ______Date: ______PT initials: ______</p><p>4/4/12</p>