GILL PHYSIOTHERAPIST CORPORATION NORTH KAMLOOPS PHYSIOTHEARPY
550 Tranquille Road, Kamloops, BC V2B 3H4 Robinder Gill MPT, BPT (Registered Physiotherapist) Tele: (250) 376-1141 Fax: (250) 376-9050
Health Questionnaire
Patient Full Name
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please check the appropriate answer:
Rows
Yes
No
Do you have diabetes?
Any heart conditions?
Respiratory system, lung issues
Do you have a pacemaker?
Do you have cancer (malignancy)?
Do you have osteoporosis/osteopenia?
Any factures/broken bones?
Active infections/flu
Have you ever had a blood transfusion?
Jaundice or Hepatitis?
Have you had a
positive
HIV test?
Any recent unexplained weight loss?
Are you taking any Blood Thinners?
Are you pregnant?
Are you taking any long tern Corticosteroids medication?
Any allergies?
Please list allergies, if selected above
Have you recently had any of the following pertaining to the area of pain?
Rows
Yes
No
Cortisone shot
X-ray
MRI
CAT scan
Ultra Sound
Surgery
Please list surgeries if selected above
What health conditions are you taking medication for?
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