To ensure you receive a complete and thorough evaluation, please provide us with the important background information on the following form

Name: _______________________________________________________________ Date:_____________
Age:
Leisure activities, including exercise routines:_________________________________________________
Occupation, including activities that comprise your workday:____________________________________

Are you on a work restriction from your doctor? Yes No Are you latex sensitive? Yes No
Do you smoke? Yes No
Do you have a pacemaker? Yes No
FOR WOMEN: Are you currently pregnant or think you might be pregnant? Yes No
ALLERGIES: List any medication(s) you are allergic to: _______________________________________
Have you RECENTLY noted any of the following (check all that apply)?
 fatigue
 difficulty maintaining balance while walking  difficulty swallowing  changes in bowel or bladder function
Have you EVER been diagnosed with any of the following conditions (check all that apply)?
 cancer
 sexually transmitted disease/HIV  chemical dependency (i.e., alcoholism)  other issue not listed___________________ Has anyone in your immediate family (parents, brothers, sisters) EVER been diagnosed with any of the
following conditions (check all that apply)?
 cancer
During the past month have you been feeling down, depressed or hopeless? YES NO
During the past month have you been bothered by having little interest or pleasure in doing things? YES NO
Is this something with which you would like help? YES YES, BUT NOT TODAY NO
Do you ever feel unsafe at home or has anyone hit you or tried to injure you in any way? YES NO
Please list any medications you are currently taking (INCLUDING pills, injections, and/or skin patches):

1. ______________________ 2._________________________ 3.______________________________
4. ______________________ 5. _________________________ 6.______________________________
Have you ever taken steroid medications for any medical conditions? YES
Have you ever taken blood thinning or anticoagulant medications for any medical conditions? YES
Have you ever taken or recently changed your dosage of Statin cholesterol-lowing drugs (Lipitor, Simvastatin or
Zocor, Mevacor)? YES
Have you taken Fluroquinoline antibiotics (Cipro, Levaquin, Floxcin, Noroxin, Vigamox, Avelox) in the past 6
months? YES
Please list any surgeries or other conditions for which you have been hospitalized, including dates:
1. ______________________ 2._________________________ 3.______________________________
Diagnosis: _________________ What date (roughly) did your present symptoms start?__________________
What do you think caused your symptoms? ____________________________________________________
My symptoms are currently:
 Getting Better  Getting Worse  Staying about the same
I should not do physical activities that (might) make my pain worse:  Disagree  Unsure  Agree
Treatment received so far (chiropractic, injections, surgery, etc) ___________________________________
Please list special tests performed for this problem (x-ray, MRI, labs, etc) ___________________________
What, if any, restrictions have been imposed by your physician? ___________________________________

Have you ever had this problem before:  Yes  No When__________ Treatment rec’d_____________
How long did it take for you to feel better? _____________________________________________________
Body Chart:
feel symptoms on the chart to the right with
the following symbols to describe your symptoms:
 Shooting/sharp pain
 Dull/aching pain
||| Numbness
= Tingling

For the therapist:
+/- Saddle Anesthesia
+/- Cough/Sneeze
+/- Bowel/Bladder Change
My symptoms currently:  Come and go  Are Constant  Are constant, but change with activity
Aggravating Factors: Identify up to 3 important
List 3 important activities that you are having positions/activities that make your symptoms worse: difficulty with as a result of your symptoms. Rate 1._________________________________________ each activity according to your ability to perform 2._________________________________________ 3._________________________________________ 10 = able to perform at pre-injury level Easing Factors: Identify up to 3 important positions
1. _______________________________________ or activities that make your symptoms better: 2. _______________________________________ 1._________________________________________ 3. _______________________________________ 2._________________________________________
3._________________________________________

How are you currently able to sleep at night due to your symptoms?
 No problem sleeping  Difficulty falling asleep  Awakened by pain  Sleep only with medication
When are your symptoms worst?  Morning  Afternoon
When are your symptoms the best?  Morning  Afternoon

Using the 0 to 10 the scale, with 0 being “no pain” and 10 being the “worst pain imaginable” please describe:
Your current level of pain while completing this survey: 0
The best your pain has been during the past 24 hours: The worst your pain has been during the past 24 hours:

Source: http://www.gosportstherapy.com/files/pdf/1-Medical%20History%20Form%202013.pdf