Physicians Quality Care

Please fill out this form AFTER you have made an appointment at Physicians Quality Care Physical Therapy.

Name

Age

Home Phone

Cell Phone

Occupation

Allergies List any medication(s) you are allergic to:

Are you sensitive to latex?

Yes No

Have you declared the Advanced Clinical Directive of Do Not Resuscitate?

Yes No

Are you currently pregnant or think you may be?

Yes No

Please list any surgeries, injuries, or other conditions for which you have been hospitalized, including approximate date and reason for surgery or hospitalization:

Date	Reason for Surgery/Hospitalization

Current Medications

Please include all prescriptions, over-the counter medications, herbal and vitamin/mineral/dietary (nutritional) supplements with each medication's name, dosage, frequency and administered route (oral, injection, etc).

Medication	Dosage	How often	Reason for taking

Add Another Row

Pain Scale

Please rate your current level of pain. Circle the corresponding number on chart. During our evaluation we will discuss the minimum and maximum pain levels you have been experiencing throughout your painful time.

Fall Assessment

Have you experienced 2 or more falls in the past year or any fall with injury in the past year? If yes please list if fall was with or without injury.

Yes No

Were you injured? Yes No

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Physical Therapy Health History

Current Medications

Pain Scale

Fall Assessment