Physical Therapy Medical History and Initial Assessment Form

Patient Information

• Full Name: _________________ Date of Birth: _________________
• Address: _________________ Phone: _________________
• Email: _________________ Emergency Contact: _________________

Current Condition

• Primary Complaint: _________________
• Date of Onset: _________________
• Injury Related? □ Yes □ No
• If yes: □ Work □ Auto □ Sports □ Other: _________________

Pain Assessment

• Pain Level (0-10): _____
• Pain Character: □ Sharp □ Dull □ Burning □ Throbbing □ Other: _____
• Pain Location (mark on body diagram): [Body Diagram Placeholder]

Medical History

Previous Medical Conditions

□ Arthritis □ Heart Disease □ Diabetes □ High Blood Pressure □ Cancer □ Other: _________________

Surgical History

Current Medications

• Name: _________________ Dosage: _________________
• Name: _________________ Dosage: _________________

Functional Assessment

Activities of Daily Living Impact

• Work/Occupation: _________________
• Current Work Status: □ Full duty □ Modified duty □ Not working
• Difficulty with:
  • □ Standing □ Walking □ Sitting □ Lifting
  • □ Stairs □ Sleep □ Other: _________________

Previous Physical Therapy

• Have you had PT before? □ Yes □ No
• If yes, when and for what condition? _________________

Goals

What do you hope to achieve through physical therapy?

Authorization

I certify that the above information is accurate to the best of my knowledge.

Signature: _________________ Date: _________________