Excel Medical History
Uploaded by
Grayson Carwile CampbellExcel Medical History
Uploaded by
Grayson Carwile CampbellPatient Name: _____________________DOB: _______
Date: ________________________________________
Referring Physician: ____________________________
Primary Care Physician: _________________________
Excellent Care. Exceptional Results.
Medical History
Accidents, injuries, or major illnesses including motor vehicle (include date):
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Surgeries (include date): ____________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Medications, vitamins: _____________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Are you pregnant?
Yes
No
If so, how many months? ______________
Do you have now or ever been diagnosed with:
High or low blood
pressure
Diabetes
Cancer
Hepatitis or jaundice
Anemia
Palpitations
Blood disorders
Lightheadedness
Heart disease
Chest pain / tightness
Stroke
Circulation / blood
clots
Bronchitis
Pneumonia
Persistant cough
Tuberculosis
Gall bladder disease
Asthma
Shortness of breath
Swollen ankles
Gout
Kidney disease
Kidney stones
Difficulty urinating
Frequent urination
Abdominal pain
Colitis
Indigestion
Nausea
Vomiting
Unexplained weight
loss
Change in bowel
habits
Constipation
Diarrhea
Blood in stools
Hemorrhoids
Severe headaches
Anxiety
Depression
Thyroid disease
Low back problems
Osteoarthritis
Rheumatoid arthritis
Skin diseases
Ulcers
Joint / tendon / muscle
pain
Joint replacement
Poor balance / falls
Other_____________
Provide details regarding conditions checked above:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_____________________________________________________________________
Have you recently noted:
Weight loss / gain
Fatigue
Fever / chills / sweats
Night sweats
Nausea / vomiting
Dizziness
Pain at night
Difficulty sleeping
Weakness
Shortness of breath
Difficulty swallowing
Difficulty concentrating
Numbness / tingling
Headaches
Change of appetite
Falls
Please rate your health:
Excellent
Do you exercise? YES NO
Good
Fair
Poor
If yes, how often _________________________________
What type of exercise? _____________________________________________________
Was the onset due to: Injury Motor vehicle accident Slow onset Chronic Work related
Repetitive motion Sports Recreational Trauma Unknown Other ___________
Briefly describe why you are here today, (Describe the condition and date of onset):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Diagnostic testing Performed: Nerve conduction velocity EMG Bone scan MRI
Cardiac stress test CT scan Blood test Urinalysis Doppler studies x-rays
Other______
Results from testing: ________________________________________________________________
What is your pain intensity on average? (0 = no pain, 10 = worst imaginable)__________________
At its worst _________At its best __________At rest __________ At night _________Movement___________
Movements that increase pain ________________________Movements that decrease_____________________
Does the pain radiate and if so where: ___________________________________________________________
When is the pain the worst: Morning / Afternoon / Night
Please indicate where your pain or symptoms are by shading areas below:
Describe the Pain (Mark all):
Sharp
Dull
Achy
Burning
Stabbing
Throbbing
Pulsating
Deep
Boring
Shooting
Searing
Radiating
Tearing
Terrifying
Ripping
Other___________
Do you have: Pins and needles Numbness Tingling Loss of sensation Hypersensitivity
Strength loss? If so, where:_______________________________________________________________
What are your goals for Physical Therapy?
________________________________________________________________________________________
________________________________________________________________________________________
I certify that the above information is correct to the best of my knowledge. I have disclosed all
medical conditions that I am aware of and will inform my practitioner of any changes in my health
status. I understand that these services are a health aid and not a substitute for a doctors care.
Signature:___________________________________________________ Date:______________
