NAME:_______________________________________________ DATE:___________________________

Health History:
Please indicate if you have ever been diagnosed with, treated for, and/or experienced symptoms of any of the following:
Kidney Disease____________________________
Angina/Chest Pain__________________________
Heart Attack/Heart Disease___________________
High/Low Blood Pressure____________________
Diabetes__________________________________
Shortness of Breath_________________________
Asthma/Emphysema________________________
Dizziness/Syncope_________________________
Seizures__________________________________
Bowel/Bladder Problems_____________________
Rectal/Vaginal Bleeding_____________________
Osteoporosis______________________________
Cancer___________________________________
Rheumatic Fever___________________________
Tuberculosis/TB___________________________
Hepatitis_________________________________
Stroke/TIA___________________________________
Arthritis______________________________________
Circulation Problems/Phlebitis____________________
Muscle/Nerve Disorder
Tobacco Use (smoking/chewing)
Alcohol Use
Number of falls in Past Year? ___________
Injuries from the fall/falls: ____ YES ____NO
Describe:_____________________________________

Recent surgeries:________________________________
Accidents
Auto______________________________________
Workers Comp______________________________
Other:_____________________________________
Describe

Are you experiencing any of the following?
Unexplained cough of 2 weeks or more
Unexplained weight loss/gain
Loss of appetite
Night sweats
Unexplained fever
Bloody sputum

Please list the medications that you currently are taking and the dosage:
Name of medication: Dosage: When do you take the medication?




Pain Log: Please circle areas that you are experiencing Pain Rating: Please circle one of the following
pain and/or altered sensation. that best describes your pain today.
Is this pain/altered sensation continual? ___YES ___NO
0-No pain
1- What would you
2-weak pain rate as your worse
3-moderate pain pain?__________
4-
5-strong pain What would you
6- rate as your best
7-very strong pain pain?__________
8-
9-very, very strong pain
10- Maximal pain

1599 North Hermitage Road, Hermitage, Pa 16148
724-962-7920
565 W Neshannock Ave, New Wilmington, PA 16142
724-946-3313
www.pennohiorehab.com