Health History

Patient Name *

Today's Date * +

Clinic Where Appt is Scheduled? *

Current Weight *

Current Height *

Primary Care Physician Name *

Are you currently employed? *

No

Retired

Yes, Name of Employer Yes, Name of Employer

Are you employed? *

Full Time

Part Time

Seasonal

N/A Not Applicable

Current Job Title/Occupation?

Is this injury/pain accident related to? *

If Workers' Compensation, who can we contact are your job to obtain claim information?

Have you retained an Attorney to represent you for this injury? *

No	Yes, Attorney's Name and Phone # Yes, Attorney's Name and Phone #

What side of the body is your injury/pain? *

Left Side	Right Side
Both Sides	N/A NOT APPLICABLE

Date of Injury/Onset Date/Date Pain Started? * +

Was surgery performed on this injury/pain? *

No	Yes, Date of Surgery/Type of Surgery Yes, Date of Surgery/Type of Surgery

Have you been hospitalized within the past 12 months? *

No	Yes, Hospitalization Dates Yes, Hospitalization Dates

What happened to cause this injury/pain? *

Where did this accident/injury occur? (Ex: work, parking lot, home, street)

Main reason for needing Physical Therapy?

*


	1	2	3	4	5	6	7	8	9	10
Pain at WORST	1	2	3	4	5	6	7	8	9	10
CURRENT Pain	1	2	3	4	5	6	7	8	9	10
Pain at BEST	1	2	3	4	5	6	7	8	9	10

Describe your pain (check all that apply) *

Does any of the following aggravate your injury/pain? (check all that apply) *

What makes your pain WORSE? *

What makes your pain BETTER? (ex: ice, heat, medication, rest) *

Have you ever experienced this same injury / pain before? *

No	Yes, Please Explain Yes, Please Explain

Rate your general health *

Good

Fair

Poor

Social History *

Duty Level *

Did your physician take you off of work? *

N/A

No

Yes, Dates Yes, Dates

Are you a tobacco user? *

Have you been a patient of Genesis in the past? *

No	Yes, What Year? Yes, What Year?

Are you currently receiving Home Health Care or Hospice Care? *

Do you have a history of falls (fallen 2 or more times within the past 12 months)? *

No - skip next question

Yes - proceed to next question

What is the main contributing factor for your falls?

Mark the medical conditions that apply to you (check all that apply) *

List any past surgeries with dates (If you do not know exact date, list year)

Are you currently pregnant? *

NOT APPLICABLE

No

Yes, Due Date Yes, Due Date

Do you have a diagnosis of Depression or Bipolar Disorder? *

No

Yes

Have you had any of the following tests done for this this injury/pain? *

Have you had any Physical, Occupational, Speech, or Chiropractic Therapy for this injury/pain? *

No	Yes, Please Explain Yes, Please Explain

Have you had any Physical, Occupational, Speech, or Chiropractic Therapy since January 1 of this year? *

No	Yes, How Many Visits Yes, How Many Visits

When is your next appointment with the Physician that sent you here? *

Current Medications

Are you currently taking any medications? *

No	Yes, List them Below

Medication List - please fill out each section completely
Dosage (ex: 20mg)
Frequency (ex: once per day)
Route (Oral, Injection, Inhalation, Transdermal, Nasal, Eye, Ear)

	Name of Medication	Dosage	Frequency	Route
1	Name of Medication	Dosage	Frequency	Route
2	Name of Medication	Dosage	Frequency	Route
3	Name of Medication	Dosage	Frequency	Route
4	Name of Medication	Dosage	Frequency	Route
5	Name of Medication	Dosage	Frequency	Route
6	Name of Medication	Dosage	Frequency	Route
7	Name of Medication	Dosage	Frequency	Route
8	Name of Medication	Dosage	Frequency	Route
9	Name of Medication	Dosage	Frequency	Route
10	Name of Medication	Dosage	Frequency	Route
11	Name of Medication	Dosage	Frequency	Route
12	Name of Medication	Dosage	Frequency	Route
13	Name of Medication	Dosage	Frequency	Route
14	Name of Medication	Dosage	Frequency	Route
15	Name of Medication	Dosage	Frequency	Route

If Applicable, Attach Physical Therapy Order Here

If you are not able to finish paperwork or submit online,

please arrive to your appointment 30 minutes early to complete paperwork.

Employment/Work Injury	Auto Accident	Sports Injury
N/A NOT APPLICABLE	Other, Please Explain Other, Please Explain

Burning	Sharp	Dull/Achy	Throbbing	Shooting	Numbness/Tingling
Constant	Intermittent	Worse in AM	Worse in PM	Worse at Night	N/A NOT APPLICABLE

Sitting	Standing	Walking	Stairs-Up	Stairs-Down	Sit to Stand
Bending	Voiding	Lying Down	Cough/Sneeze	N/A NOT APPLICABLE

Reaction to Medication	Home Fall / Home Fall Hazard	Changes in Blood Pressure
Vision / Vision Problems	Other, Please Explain Other, Please Explain

NONE / NOT APPLICABLE	History of Cancer	Pacemaker/Defibrillator
Alzheimer’s	High Blood Pressure	Fibromyalgia
Cardiovascular Disease	Huntington’s	Traumatic Brain Injury
Cauda Equina Syndrome	Immunosuppression	Fracture/Suspect Fract
C.V.A./Stroke	Lupus	Parkinson’s
Current Infection	Muscular Dystrophy	Rheumatoid Arthritis
Diabetes Type 1	Obesity	Osteoarthritis
Diabetes Type 2	Other (list below)

NONE / NOT APPLICABLE	X-Ray	MRI	CT Scan	Myelogram	EMG
Test Results: Test Results: