Patient History and Physical Form
Help us to provide you with the best possible care. Please answer ALL of the following questions.
Appointment Date:
Open the calendar popup.
<<
<
February 2012
>
>>
S
M
T
W
T
F
S
5
29
30
31
1
2
3
4
6
5
6
7
8
9
10
11
7
12
13
14
15
16
17
18
8
19
20
21
22
23
24
25
9
26
27
28
29
1
2
3
10
4
5
6
7
8
9
10
First Name:
Last Name:
What is the name of the Dr. that referred you to us?
What is the medical condition of concern/ why were you referred to us?
When was this condition first noticed?
Has there been any treatment for the condition?
Yes
No
Where is the medical condition located?
Any Physical Therapy? (If Applicable)
Yes
No
Any X-Ray, CT Scans, MRI? (If Applicable)
Yes
No
If yes, please explain in detail
Any Allergies?
Yes
No
Any Medications?
Yes
No
Birth History
Birth Weight:
Birth Length:
Gestation Age:
Vaginal
C-Section
Where there any complications at delivery?
Yes
No
If yes, please explain in detail
Health History
Are there any other illnesses or conditions?
Yes
No
If yes, please explain in detail
Are immunizations current?
Yes
No
Has there been any surgeries or procedures of any kind?
Yes
No
If yes, please explain in detail
Family History
Please list all family members that have medical conditions.
(e.g. Maternal Grandmother-High blood pressure)
Social History
Parent's marital status:
Any Siblings:
Siblings Description
What is the school grade level?
Is there any involvement in sports or clubs of any kind?
Yes
No
If yes, please explain in detail
