Patient History and Physical Condition

1. Have you ever had?: (If yes, explain)
High Blood Pressure            No    Yes    _______________________________
Heart or Circulation Disorder  No    Yes    _______________________________
Seizures                       No    Yes    _______________________________
Dizzy Spells                   No    Yes    _______________________________
Diabetes                       No    Yes    _______________________________
Cancer                         No    Yes    _______________________________
Osteoporosis                   No    Yes    _______________________________
Arthritis/Osteoarthritis       No    Yes    _______________________________
Immune Deficiency Disease      No    Yes    _______________________________

2. Please list surgeries you have had, give procedures and dates, if possible:

_____________________________________________________________________________________

3. Please list recent diagnostic studies (Cat-Scan, MRI, X-Rays):

_____________________________________________________________________________________

4. Do you have any METAL anywhere in your body: pins/plates post fracture or pacemakers (other than teeth? No □ Yes □   If so, Describe:

_____________________________________________________________________________________

5. Are you pregnant?  No □  Yes □    Date of last menstrual cycle ______________
6. Do you have any abnormal trouble with vision? No □  Yes □ Hearing? No □  Yes □

7. List any allergies: ________________________________________________________
8. Have you ever taken steroid or anti-coagulants for an extended period of time?
   No □  Yes □
9. Have you had an unusual weight gain or loss lately? No □  Yes □

10. List Medications you are taking: __________________________________________

11. Have you ever had physical therapy treatments before? No □  Yes □
If yes, please indicate where, when and for what problem: _____________________

_______________________________________________________________________________

12. For what problem has your doctor ordered physical/occupational therapy?

_______________________________________________________________________________

13. Describe briefly the history of your present Accident, Injury or Illness:

Onset Date: _________________ Description:_____________________________________

_______________________________________________________________________________

14. Date of next doctor's appointment: ____________________

Patient, Parent or Guardian Signature __________________________________ Date ___________