Hansen Physical Therapy, PLLC – Medical Screening

Medical History Form

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Date

Name*

First Last

Email*

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Date of Birth*

Medical History Screening

What is the reason for your visit today?

Please indicate whether you have, or have had any of the following problems; include dates. This information will help us create a safe effective treatment plan. Certain types of therapy are not used depending on your medical status/history.

Cancer

Yes
No

Date

Diabetes

Yes
No

Date

Low Blood Sugar

Yes
No

Date

High blood pressure

Yes
No

Date

Heart Disease

Yes
No

Date

Angina or chest pain

Yes
No

Date

Stroke

Yes
No

Date

Allergies

Yes
No

Date

Neurological Disease

Yes
No

Date

Latex Allergies

Yes
No

Date

Asthma/Hay Fever

Yes
No

Date

Kidney Disease/Stones

Yes
No

Date

Emphysema

Yes
No

Date

Anemia

Yes
No

Date

Ulcers

Yes
No

Date

Shortness of Breath

Yes
No

Date

Arthritis /Gout

Yes
No

Date

Mental Illness /Depression

Yes
No

Date

Urinary Tract Infection

Yes
No

Date

Cirrhosis/Liver Disease

Yes
No

Date

Polio

Yes
No

Date

Rheumatic/Scarlet Fever

Yes
No

Date

Pneumonia

Yes
No

Date

Do you have a pacemaker?

Yes
No

Date

Are you currently being treated for any illness or infection?

Yes
No

Other

Have you ever been prescribed corticosteroid medications? (e.g. Prednisone)

Yes
No

Are you taking any medications for any condition? If so, please list:

Have you ever had an allergic reaction to a medication? If so, which one?

Do you use any tobacco products?

Yes
No

Alcohol?

Yes
No

Alcohol Frequency?

Are you on a special diet prescribed by a medical provider?

Yes
No

Have you had any operations or hospitalizations? If so, please list:

Have you had any unexplained weight loss/gain of greater than 10 lbs in the last 6 months?

Yes
No

Is your current problem a result of domestic violence?

Yes
No

Are you pregnant?

Yes
No

Are you nursing?

Yes
No

Do you have any loss of bowel or bladder control?

Yes
No

Have you had any specific diagnostic tests (e.g. x-rays, MRI, etc.) done for this problem?

Yes
No

Results of tests (if known):

Home/Work Environment

Occupation:

Please check all the activities that are included in your job/daily activities:

prolonged sitting (desk, computer, driving)
prolonged standing (equipment operation, sales clerk)
prolonged walking (delivery service)
use of large or small equipment (computer, telephone, fork lift, drill press, cash register)
lifting, bending, twisting, climbing, turning
exposure to chemicals or gases
other

Please describe other

Phone

This field is for validation purposes and should be left unchanged.

Medical History Screening - Hansen Physical Therapy, PLLC

Medical History Form

Medical History Screening

Home/Work Environment