Confidential Health History Form - Competitive Edge Physiotherapy

Name

First Last

Please briefly write in your words the primary reason for your physiotherapy consult (e.g. back & leg pain)

FOR WOMEN: Are you currently pregnant or think you might be pregnant?

Yes
No

Do you currently have or have had a history of any medical condition(s)? Please check all that apply)

If selected other, please indicate

Any surgeries:

Within the past year, have you had any of the following symptoms? (Please check all that apply)

Have you recently had any unexplained weight loss? Loss of appetite? Night sweats?

Yes
No

Do you have unrelenting/constant night pain?

Yes
No

Do you have a history of oral steroid use? (e.g. cortisone, prednisone)

Yes
No

During the last month, have you often been bothered by feeling down, depressed or hopeless?

Yes
No

During the last month, have you often been bothered by little interest or pleasure in doing things?

Yes
No

Please tell us what your (3) primary goals are or what you wish to achieve with your treatments: (e.g. return to playing tennis 3x a week, return to my full-time work as of…,be able to walk for 30 minutes, eliminate headaches)

Goals can be listed as point form or in paragraph form.