Body in Balance Physical Therapy Medical History Questionnaire Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY What brings you to the clinic today? How long has this been bothering you?(Required)What makes it feel better? Worse?(Required)Have you ever been treated for this problem before?(Required)Have you ever been diagnosed as having any of the following conditions?Heart Problems(Required) Yes No Diabetes(Required) Yes No Thyroid Problems(Required) Yes No Epilepsy/Seizures(Required) Yes No Cancer(Required) Yes No Hypertension (high blood pressure)(Required) Yes No Blood disorders (e.g. anemia, hemophilia)(Required) Yes No Asthma/breathing problems(Required) Yes No Gastrointestinal disorders(Required) Yes No Neurological disorders(including stroke)(Required) Yes No Arthritis(Required) Yes No Attention deficit hyperactive disorder(Required) Yes No Depression/Anxiety(Required) Yes No Panic attacks(Required) Yes No Have you recently experienced any of the following?Change in bowel/bladder habits(Required) Yes No Unexplained weight loss or gain(Required) Yes No Have you been exposed to any communicable/infectious diseases? (e.g. Tuberculosis, Hepatitis, HIV)(Required) Yes No Is there any possibility that you are currently pregnant?(Required) Yes No N/A Please list any past injuries for which you have been treated and any previous surgeries (include approximate date):(Required)Please list any medications you are currently taking (including non-prescription):(Required)Signature(Required)Date MM slash DD slash YYYY CAPTCHA Back to Patient Forms Page
