FAMILY/PERSONAL HISTORY

DATE:____________________

PATIENT'S NAME ___________________________ DOB __________________ AGE ________________

DIAGNOSIS_________________________________________ DATE OF ONSET ____________________
PHYSICIAN ___________________ THERAPIST ___________________ Precautions__________________

Past Medical History

Have you or any immediate family member ever been told you have:

Circle One:
(DO NOT Complete) For the Therapist:
Relation for Patient Date of Onset Current Status
Cancer YES NO
Diabetes YES NO
Hypoglycemia YES NO
Hypertension or High blood presure YES NO
Heart Disease YES NO
Angina or Chest Pain YES NO
Shortness of BReath YES NO
Stroke YES NO
Kidney Disease YES NO
Urinary Tract Infection YES NO
Allergies YES NO
Asthma, Hay Fever YES NO
Rheumatic/Scarlet Fever YES NO
Hepatitis/Jaundice YES NO
Cirrhosis Liver Disease YES NO
Polio YES NO
Chronic Bronchitis YES NO
Pneumonia YES NO
Emphysema YES NO
Migraine Headache YES NO
Anemia YES NO
Ulcers/Stomach Problems YES NO
Arthritis/ Gout YES NO
OTHER YES NO

Family/ Personal History (continued)

1. Are you taking any prescription or over the counter medication?
yes no if yes:______________________
2. Have ou had any x-rays, sonograms, computed tomography (CT) scans, or magnetc resonace imaging (MRI)
done recently?
yes no if yes:______________________
3. Have you had any laboratory work done recently (urinalysis or blood test)?
yes no if yes:______________________
4. Please list any operations that you have ever had and the date of surgery
Surgery: Date:

GENERAL HEALTH
1. Have you has any recent illness within the last 3 weeks (e.g. colds, influenza, bladder or kidney infection)?
yes no
2. Have you noticed any lumps of thickening of skin or muscle anywhere on your body?
yes no
3. Do you have any sores that have not healed or any changes in size, shape, or color of wart or mole?
yes no
4. Have you had any unexplained weight loss in the last month?
yes no
5. Do you smoke or chew tobacco?
yes no
if yes, how many packs/ day?_______________ for how many months or years?___________________
6. How much alcohol do you drink in the course of a week?_________________
7. How much caffeine do you consume daily ( including soft drinks, coffee, tea, or chocolate)
8. Are you on any special diet prescribed by a physician?
yes no

Special questions for Women

1. Last pap Smear