Physical Therapy Patient History

Name___________________________________
Today’s Date____________________
Age_____ Height______ Weight______ Sex: Male/Female Handedness: Right/Left
Occupation_________________________________________________________________________
Are you currently off work because of this problem?   Yes  No  Light duty
Diagnosis______________________________ Referral source________________________________
When did your problems begin?_________________________________________________________
How did your problems begin?_______________________________________
_______________________________________________________________
	
Rate your pain: No Pain   0    1    2    3    4    5    6    7    8    9    10   Worst Pain

Draw your pain: 
Describe your pain:  Dull   Ache
 Sharp  Stabbing  Pins & Needles
Shooting Pain  Burning  Throbbing
 Twinge  Numbness/Tingling
 Other_________________________
Is your pain constant?  Yes  No
Intermittent?  Yes  No
Fluctuates with activity?  Yes  No
Wakes you up at night?  Yes  No

What makes your symptoms worse?
 Sitting  Standing  Walking
Lifting  Bending  Lying down
 Squatting  Stress  Other_______________________________________
Are you ever totally pain free?  Yes  No

What makes your symptoms better?  Sitting  Standing  Walking  Lifting
 Bending  Lying down  Other____________________________________

What time of day are your symptoms worst? ___________ Best?____________

Do you feel you are:   Getting better     Getting worse      Staying the same

Have you had this problem before?  Yes  No
If yes, when and how did it get better?__________________________________
________________________________________________________________
Any previous treatment for your current condition?  Yes  No

Have you had diagnostic studies for your current condition? (X-ray, MRI, CT scan...)
 Yes  No

Any other orthopedic problems?  Yes  No 
If yes, please explain:_______________________________________________
________________________________________________________________

Any medical problems?  Yes  No
If yes, please explain:_______________________________________________
________________________________________________________________

Any surgeries?  Yes  No
If yes, please explain:_______________________________________________
________________________________________________________________

Please list ALL medications you are currently taking such as prescription and over-the-counter for this and any other condition:______________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

Have you ever had a history of any of the following?  Major injury to head/spine
 Cancer/tumors  Osteoporosis  Dizziness/blackouts  Heart problems/angina
 Diabetes  Pacemaker  Sudden weight loss/gain  Severe pain at night
 Smoking  Bruising easily  Asthma  Frequent falls  Loss of bowel/bladder control  Numbness  Seizures/epilepsy  High blood pressure  Coordination
loss

Does your current condition limit you in carrying out job duties?  Yes  No
Household duties?  Yes  No

What are your goals in physical therapy?_______________________________
________________________________________________________________
________________________________________________________________

Thanks for taking the time to fill out this form as completely as possible! It will save us on treatment time during your first visit and will help in assessing your condition and guiding your treatment plan.