balancedbodyrehab_Patient_History

Balanced Body Rehab Patient History Form
1. Please enter your information
Name

First NameMiddle InitialsLast Name
Street Address
City
State
Apt/Unit #
Zip Code
Date of Birth

MonthDayYear
Gender

FemaleMaleNon-BinaryDeclined to answer
Height
Weight
Mobile Phone
Home Phone
Preferred contact method

Mobile phoneHome phoneEmail
Email
example@example.com
Whom may we thank for this referral?
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Number
2. Please enter your Physician's information
Physician's First and Last Name
Physician's Office Number
Physician's Office Fax Number
Physician's Address
3. Medical History
What is the primary source of pain?
Are you currently or have you recently experienced any type of pain, numbness or tingling? If so, please describe your symptoms including when and how your symptoms began (ie. accident, non-specific, gradual onset, etc.):
What makes your symptoms worse?
What makes your symptoms better?
Describe the nature of your symptoms:

SharpShootingDull AcheBurningNumbTingling
How often do you experience your symptoms?
How are your symptoms changing?
In general, would you say your overall health right now is...
Have you had similar symptoms in the past?
During the past 4 weeks, indicate the average intensity of your symptoms on a 1-10 scale, with 1 being no pain and 10 being unbearable pain.
Do your symptoms/condition limit you from performing any activities (ie. work, recreation, social functions, house chores) If so, please describe:
Have you received treatment for this condition by another health care professional?

YesNo
If yes, please explain:
Briefly describe your recreational activities:
Briefly describe your current physical fitness activities:
List any past operations and/or medical procedures including when and where:
Have you ever had any cosmetic surgery procedures? For example: breast augmentation, facial rejuvination, reconstructive surgery.
List any tests you have had performed: (MRI, CT Scan, X-rays, Blood work) relating to your symptoms:
Are you allergic to any type of adhesives or latex?
Please list any medications you are currently taking and reasons for use:
Have you or do you currently have any problems with incontinence? If so when/how often?
Have you had a complete medical check-up in the past year? Y / N If so, what were the results?
Have you been treated or recently been troubled with any of the following? Please check all that apply.

DepressionBipolar disorderPain or a feeling of heaviness in your chestHeart ConditionPulsating pain anywhere in your bodyConstant and severe pain in the lower leg (calf)Persistent pain at nightUnexplained weight loss (10 lbs in one week)Dizziness/Fainting spellsSmoking history/lung conditionsSwelling/bruisingSkin lesions or rashesConstant pain anywhere in your bodyPain with coughing or sneezingLoss of appetiteUnusual lumps or growthsChronic FatigueFrequent or severe abdominal painFrequent heartburn or indigestionFrequent nausea or vomitingUnusual menstrual irregularitiesChanges in hearingFrequent or severe headachesProblems swallowing/changes in speechChanges with vision (blurred vision or loss of sight)Problems with balance or fallingDifficulty going to sleep/staying asleepSeizuresSudden weaknessFever/night sweatsRecent severe emotional disturbancesSwelling or redness in any jointsPregnantHepatitis/HIVDentures/Splints/BracesConfusion/Memory lossHigh blood pressureDiabetesHigh cholesterol
Are you currently or do you have a history of taking corticosteroids or medications for bone density?
Have you ever had an exercise stress test?
If yes, what were the results?
Have you recently been hospitalized?
If yes, explain:
List any physical aids currently used (cane, hearing aid, glasses, prosthetics, etc):
List any other medical history not described above and any medical condition you are currently being treated for:
Please describe anything else you want us to know:
4. Please notate all current medications that you are taking including ALL; prescriptions, over the counter medicine, herbals, vitamins and nutritional supplements:
Medications
Dosage
Frequency
Route of Ingestion
5. Have you had a fall with an injury or two falls in the past 12 months?

YesNo
6. Is anyone in your home making you feel unsafe or causing you physical, mental or emotional harm? If yes, would you like assistance finding resources to help you?
Appointments cancelled with less than 24-hours’ notice will be subject to a 50% cancellation fee. Any Medicare appointment cancelled with less than 24 hours will be subject to a $25.00 per 25 min fee. Balanced Body Rehab reserves the right to assess a late cancellation fee for ANY visit with less than a 24-hour notice.
Signature

Clear
I acknowledge medical information I have provided above is accurate to the best of my knowledge. If you are under the age of 18, a parent or legal guardian is required to sign on the line below.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Balanced Body Rehab Patient History Form

1. Please enter your information

2. Please enter your Physician's information

3. Medical History

4. Please notate all current medications that you are taking including ALL; prescriptions, over the counter medicine, herbals, vitamins and nutritional supplements: