Subjective Medical History (see evaluation for objective measures)

 

 

Name                                                                            Age                 Physician                                                       

 

To ensure you receive a complete and thorough initial evaluation at Mitchell Physical Therapy, please provide us with the important background information on this form. If you do not understand a question, your therapist will assist you. Please note: all content regarding your medical history is kept confidential. Thank you.

Check any condition that applies:

Allergies                                             Diabetes                                              Kidney disease                                  Pregnant

Anemia                                                Dizziness                                             Multiple Sclerosis                             Rheumatoid

Arthritis                                              Emphysema/Bronchitis                    Nausea                                                Ringing in ears

Asthma                                               Epilepsy                                              Numbness                                          Stroke

Balance or gait disturbance             Headaches                                          Pacemaker                                           Thyroid problems

Blurred vision                                    Heart problems                                  Pain with coughing/sneezing          Tuberculosis

Bowel or bladder changes               Hepatitis                                             Pain with deep breath                       Weakness

Cancer                                                 High blood pressure                         Peptic Ulcer                                         other:                 

Chemical dependency                                                                                                                                     

PLEASE CIRCLE THE ANSWERS BELOW THAT APPLY.

 

Do you have a pacemaker: yes   no     Do you smoke: yes   no                        packs a day

Is there any chance you could be pregnant?    yes    no

Past Surgery: Spine    Knee    Shoulder    Hip    Heart    other                                                                                   

 

What was the date of your injury?                                                               

Please tell us how your injury/illness began                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    

Physical Therapy goals: Return to    Work    Sport    Hobby    Daily Living                                                   

 

Pain Increases with:  Activity     Lying down     Sitting     Standing     Driving     Medication

 

Pain Decreases with:  Activity     Lying down     Sitting     Standing     Driving     Medication

 

Work Status:  Light Duty    Off Work    Normal Schedule    Retired    Disabled

 

Please list any medications you are taking:                                                                                                 

                                                                                                                                                                                   

What prior tests/treatment have you had for this problem?

            X-Ray                                      Arthrogram    

            MRI                                         Physical Therapy    

            CT Scan                                   Injections    

            Bone Scan                                Other (please describe)                                                

 


 

Please indicate areas of pain/numbness below

 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Numbness  ////              Moderate Pain XX

Severe Pain                  Shooting Pain

 

 

 

 
 
 


                                                                                                               

 

 

 

 

 

 

 

Current pain severity (please circle one):

None 0    1    2    3    4   5   6   7   8   9   10 Worst

 

Is your current condition:

Getting better    Getting worse    staying the same?

 
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 


I understand that all medical information listed above will be kept confidential in accordance with Mitchell Physical Therapy’s Privacy Policy.

 

All information is true and correct to the best of my knowledge.

 

 

                                                                                                                                               

Patient Signature                                                                                Today’s Date