FAMILY/PERSONAL HISTORY			Date: _________________________________________
Client’s Name: ___________________________________ DOB: __________________ Age: _______
Race/ethnicity:	□ American Indian/Alaska Native	□ Asian
	□ Black/African American	□ Caucasian/white
	□ Hispanic/Latino	□ Native Hawaiian/Pacific Islander
	□ Multi-racial	□ Other/unknown
Language:	 □ English understood	□ Interpreter needed
	 □ Primary language:
Medical Diagnosis: ________________________________ Date of onset: _______________________
Physician: _____________ Date of surgery (if any): ______________ Therapist: __________________

Personal History
Have you ever had:
• Anemia	Yes	No	• Chronic bronchitis	Yes	No
• Epilepsy/seizures	Yes	No	• Emphysema	Yes	No
• Fibromyalgia/myofascial pain	Yes	No	• GERD	Yes	No
  syndrome			• Gout	Yes	No
• Hepatitis/jaundice	Yes	No	• Guillain-Barré
• Hypoglycemia	Yes	No	    Syndrome	Yes	No	
• Joint replacement	Yes 	No	• Parkinson’s disease	Yes	No
• Polio/postpolio	Yes	No	• Peripheral vascular
• Shortness of breath	Yes	No	    disease	Yes	No
• Skin problems	Yes	No	• Pneumonia	Yes	No
• Rheumatic/scarlet fever	Yes	No	• Prostate problems	Yes	No
• Urinary incontinence problems 	Yes	No
     (dribbling, leaking)	Yes	No	• Thyroid problems	Yes	No
• Urinary tract infection	Yes	No	• Ulcer/stomach 
• Varicose veins	Yes	No		
For women:
History of endometriosis		Yes	No
History of pelvic inflammatory disease		Yes	No
Are you/could you be pregnant?		Yes	No
Any trouble with leaking or dribbling urine?		Yes	No
Number of pregnancies ____________		Number of live births ____________
Have you ever had a miscarriage/abortion?		Yes	No

General Health
 1. I would rate my health as (circle one):          Excellent		Good		Fair		Poor
 2. Are you taking any prescription or over-the-counter medications?		Yes	No
	IF YES, PLEASE LIST ON SEPARATE SHEET:
 3. Are you taking any nutritional supplements (any kind, including		Yes	No
	vitamins) IF YES, PLEASE LIST ON SEPARATE SHEET:
 4. Have you had any illnesses within the last 3 weeks (e.g., colds,		Yes	No
	influenza, bladder or kidney infection)?
	If yes, have you had this before in the last 3 months?		Yes	No
 5. Have you noticed any lumps or thickening of skin or muscle anywhere		Yes	No
	on your body?
 6. Do you have any sores that have not healed or any changes in size,		Yes	No
	shape, or color of a wart or mole?
 7. Have you had any unexplained weight gain or loss in the last month?		Yes	No
 8. Do you smoke or chew tobacco?		Yes	No
	If yes, how many packs/pipes/pouches/sticks a day? ____________
	How many months or years? ____________
 9. I used to smoke/chew but I quit		Yes	No
	If yes: pack or amount/day ____________         Year quit ____________
10. I would like to quit smoking/using tobacco		Yes	No
11. How much alcohol do you drink in the course of a week? (one drink is equal to 1
	beer, 1 glass of wine or 1 shot of hard liquor) ____________________________________
12. Do you use recreational or street drugs (marijuana, cocaine, crack, meth,		Yes	No
	amphetamines, or others)? If yes, what, how much, how often? ________________________
	______________________________________________________________________________

13. How much caffeine do you consume daily (including soft drinks, coffee, tea, or
	chocolate)? ____________________________________________________________________
14. Are you on any special diet?		Yes	No
15. Do you have (or have you recently had) any of these problems:
□ Blood in urine, stool, vomit, mucous	□ Cough	□ Difficulty swallowing/speaking
□ Dizziness, fainting, blackouts	□ Dribbling or leaking urine	□ Memory loss
□ Fever, chills, sweats (day or night)	□ Heart palpitations or fluttering	□ Confusion
□ Nausea, vomiting, loss of appetite	□ Numbness or tingling	□ Sudden weakness
□ Changes in bowel or bladder	□ Swelling or lumps anywhere	□ Trouble sleeping
□ Throbbing sensation/pain in belly or anywhere else	□ Problems seeing or hearing
□ Skin rash or other changes	□ Unusual fatigue, drowsiness	□ None of these
Medical/Surgical History
1. Have you ever been treated with chemotherapy, radiation therapy, biotherapy, or brachytherapy 
	(radiation implants)?	Yes	No
	If yes, please describe:
2. Have you had any x-rays, sonograms, computed tomography (CT) scans, or
	magnetic resonance imaging (MRI) or other imaging done recently?	Yes	No
	If yes, what?          When?          Results?
3. Have you had any laboratory work done recently (urinalysis or blood tests)?	Yes	No
	If yes, what?          When?          Results (if known)?
4. Any other clinical tests?	Yes	No
	Please describe:
5. Please list any operations that you have ever had and the date(s):
Operation          Date

6. Do you have a pacemaker, transplanted organ, joint replacement, breast implants, or any other implants?	Yes	No
	If yes, please describe:
7. Are you aware of what your diagnosis is?	Yes	No

8. Do you have any problems taking care of your self independently at home, or feel that you need to speak to a    social worker?	Yes	No                                                                                                                              
Work/Living Environment
1. What is your job or occupation?	
2. Military service: (When and where):	
3. Does your work involve:	□ Prolonged sitting (e.g., desk, computer, driving)
	□ Prolonged standing (e.g., equipment operator, sale clerk)
	□ Prolonged walking (e.g., mill worker, delivery service)
	□ Use of large or small equipment (e.g., telephone, forklift, computer, drill press, cash register)
	□ Lifting, bending, twisting, climbing, turning
	□ Exposure to chemicals, pesticides, toxins, or gases
	□ Other: please describe
	□ Not applicable; none of these
4. Do you use any special	□ Back cushion, neck cushion
   supports:	□ Back brace, corset
	□ Other kind of brace or support for any body part
	□ None; not applicable

History of falls:	□ In the past year, I have had no falls.
	□ I have just started to lose my balance/fall.
	□ I fall occasionally.
	□ I fall frequently (more than two times during the past 6 months).
	□ Certain factors make me cautious (e.g., curbs, ice, stairs, getting in and out of the tub).

I live:	□ Alone □ With family, spouse, partner
	□ Nursing home □ Assisted Living □ Other ________________

For the physical therapist:
Vital Signs
Resting pulse rate:	Oral temperature:
Respirations:	Oxygen saturation:
Blood pressure: 1st reading ___________________________	2nd reading _______________________
	Position:  Sitting       Standing          Extremity:  Right	Left

Past Medical History
Have you or any immediate family member (parent, sibling, child) ever been told you have:

(Do NOT complete) For the therapist:
Circle one:			Relation to Client	Date of Onset	Current Status	
• Allergies	Yes	No				
• Angina or chest pain	Yes	No				
• Anxiety/Panic attacks	Yes	No				
• Arthritis	Yes	No				
• Asthma, hay fever, or other breathing problems	Yes	No				
• Cancer	Yes	No				
• Chemical dependency (alcohol/drugs)	Yes	No				
• Cirrhosis/liver disease	Yes	No				
• Depression	Yes	No				
• Diabetes	Yes	No				
• Eating disorder   (bulimia, anorexia)	Yes	No				
• Headaches	Yes	No				
• Heart attack	Yes	No				
• Hemophilia/slow healing	Yes	No				
• High cholesterol	Yes	No				
• Hypertension or high	Yes	No				
  blood pressure	Yes	No				
• Kidney disease/stones	Yes	No				
• Multiple sclerosis	Yes	No				
• Osteoporosis	Yes	No				
• Stroke	Yes	No				
• Tuberculosis	Yes	No				
• Other (please describe)	Yes	No				
	Yes	No				
	Yes	No				
	Yes	No				

CURRRENT MEDICATIONS/ VITAMINS:

MEDICATION	DOSAGE	FREQUENCY	PLEASE INITIAL	

				

				

				

				

				

Therapists: Use this space to record
	baseline information. This
	is important in case something
	changes in the client’s status.
	You are advised to record the
	date and sign or initial this
	form for documentation and
	liability purposes, indicating
	that you have reviewed this
	form with the client. You
	may want to have the client
	sign and date it as well.

Patient Signature ______________________________________             Date ______________________

Therapist Signature ____________________________________             Date ______________________