Mission
Expertise
Orthotics
Sports/Injury Rehabilitation
Sprained Ankle Program
Performance and Testing
Home VisitsIncluding Assited Living Facilities
Vertigo/Vestibular
Geriatrics
Work Injury Management
Spine Rehabilitation/Eductation
Lower Extremity Rehabilitation
Upper Extremity Rehabilitation
Pool Therapy
Neuro Rehabilitation
Driving Assessments
Contact
About
Links
Facilities
Blog
Appointment Form
General PDF Forms
General Admit Form Online
Optimal Instrument Form Online
Medical History Form
Staff

Medical History Form

Name

MR#

Diagnosis

Check any that apply to you:

DIABETES

HIGH BLOOD PRESSURE

HEART DISEASE OR CHEST PAIN

BLOOD DISEASE (ANEMIA, AIDS, ETC.)

BREATHING PROBLEMS (ASTHMA, EMPHYSEMA, ETC.)

CIRCULATION PROBLEMS (VARICOSE VEINS, PHLEBITIS)

DIGESTIVE PROBLEMS (ULCERS, HIATAL HERNIA, ETC.)

LIVER PROBLEMS (HEPATITIS, JAUNDICE, ETC.)

PREVIOUS SURGERY

PREVIOUS FRACTURED BONES (IF SO PLEASE EXPLAIN BELOW)

HEADACHES

CANCER

ARTHRITIS

FAINTING OR DIZZY SPELLS

NIGHT SWEATS

STROKE/HEAD INJURIES

HERNIA

PREGNANT/POSSIBLY

PREGNANT

OTHER (IF SO PLEASE EXPLAIN BELOW)

Please Elaborate

Are you currently taking any precriptions, over-the-counter, herbal, and/or vitamin medications?

Are you currently engaging in any form of exercise? If so please list activity, frequency, and intensity.

How active is your lifestyle?

Sedentary

Moderate Physical Activity

Heavy Physical Activity

Describe the types of activities involved in your job (heavy lifting, stair climbing, walking, sitting at desk, etc):

Please indicate your expectations and goals for your treatment:

Please describe in detail where you are feeling pain:

Pain Frequency

Relationship of pain to sleep:

Wakes from sleep

Prevents sleep

Better after sleep

Pain Level, 1 being no pain, 10 being as bad as it can be

Signature (Please Type Full Name)

Date

Please enter the following security code:

...

Not readable? Change text.

Orthotics
Sports/Injury Rehabilitation
Sprained Ankle Program
Performance and Testing
Home VisitsIncluding Assited Living Facilities
Vertigo/Vestibular
Geriatrics
Work Injury Management
Spine Rehabilitation/Eductation
Lower Extremity Rehabilitation
Upper Extremity Rehabilitation
Pool Therapy
Neuro Rehabilitation
Driving Assessments

Mission
Facilities
Expertise

Contact
Staff
Map

Advanced Performance & Rehabilitation Services
1532 Ellis Street, Suite 210, Bozeman, Montana • 406-587-4501