Personal Information & Medical History – STEP UP Physical Therapy

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Patient Forms
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Form Instructions

Please enter the requested information below. Many of the fields require an entry. If you do not have this information or it is not applicable to you, please enter N/A or some other note in the field. Click SUBMIT when you are done.

Personal Information and Medical History

Date

MM slash DD slash YYYY

Patient Name(Required)

First Last

Age:(Required)

Date of Birth:(Required)

Height:(Required)

Weight:(Required)

Address

Street Address Address Line 2 City State ZIP Code

Home Phone:

Cell Phone:

Work Phone:

Email Address:

Emergency Contact (Name and Phone #):

Referring Physician:(Required)

Enter name of Referring Physician.

Primary Care Physician:(Required)

Enter if different than Referring Physician. Otherwise, enter N/A.

Primary Insurance:

Primary Insurance ID #/Group #:

Secondary Insurance:

Secondary Insurance ID #/Group #:

Reason for Physical Therapy:(Required)

How did this problem start?(Required)

Date of Onset:(Required)

Pain Intensity (0 to 10 where 0=none, 10=emergency):(Required)

Have you had or are you scheduled for any diagnostic tests (X-ray, MRI, etc.)?(Required)

Have you received/are you receiving any treatment for this problem (acupuncture, chiropractic, home health)?(Required)

Surgeries or past injuries (and dates):(Required)

Current medications:

Please list below or upload separate document with list of medications, see below.

Upload medications file:

Max. file size: 32 MB.

What activities are you limited in because of your problem?(Required)

What are your goals with therapy?(Required)

Do you drink alcoholic beverages?(Required)

Yes

No

How many drinks per week?

Do you or have you smoked?(Required)

Yes

No

How much?(Required)

Date you quit?

Medical Problems

Have you experienced any of the following problems (click either Yes or No)?

Bowel and bladder changes, or loss of control?(Required)

Yes

No

Numbness or tingling?(Required)

Yes

No

Headaches?(Required)

Yes

No

Angina or chest pain?(Required)

Yes

No

Heart or cardiac problems/disease?(Required)

Yes

No

High blood pressure?(Required)

Yes

No

Shortness of breath?(Required)

Yes

No

Unexplained weight loss?(Required)

Yes

No

Depression?(Required)

Yes

No

Anxiety?(Required)

Yes

No

Other psychological problems?(Required)

Yes

No

Cancer?(Required)

Yes

No

Diabetes?(Required)

Yes

No

Osteoporosis/osteopenia?(Required)

Yes

No

Osteoarthritis?(Required)

Yes

No

Rheumatoid Arthritis?(Required)

Yes

No

Asthma/hay fever?(Required)

Yes

No

Allergies?(Required)

Yes

No

Epilepsy/seizures?(Required)

Yes

No

Stroke?(Required)

Yes

No

Parkinson’s disease?(Required)

Yes

No

Multiple sclerosis?(Required)

Yes

No

Tuberculosis?(Required)

Yes

No

Hepatitis A, B, or C?(Required)

Yes

No

Self Related Health Questions

At the present time, would you say that your health is: excellent, very good, fair, or poor?

Excellent

Very Good

Fair

Poor

Is there anything else that you would like to share with us?

Yes

No

Please explain:

Hidden

Email

Hidden

AD ID

Hidden

PE ID

Hidden

Page Confirmation

Yes

No

Email

This field is for validation purposes and should be left unchanged.

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