Subjective Medical History (see evaluation for objective measures)
Name Age Physician
To ensure you receive a complete and thorough initial evaluation at Mitchell Physical Therapy, please provide us with the important background information on this form. If you do not understand a question, your therapist will assist you. Please note: all content regarding your medical history is kept confidential. Thank you.
Check any condition that applies:
Allergies Diabetes Kidney disease Pregnant
Anemia Dizziness Multiple Sclerosis Rheumatoid
Arthritis Emphysema/Bronchitis Nausea Ringing in ears
Asthma Epilepsy Numbness Stroke
Balance or gait disturbance Headaches Pacemaker Thyroid problems
Blurred vision Heart problems Pain with coughing/sneezing Tuberculosis
Bowel or bladder changes Hepatitis Pain with deep breath Weakness
Cancer High blood pressure Peptic Ulcer other:
PLEASE CIRCLE THE ANSWERS BELOW THAT APPLY.
Do you have a pacemaker: yes no Do you smoke: yes no packs a day
Is there any chance you could be pregnant? yes no
Past Surgery: Spine Knee Shoulder Hip Heart other
What was the date of your injury?
Please tell us how your injury/illness began
Physical Therapy goals: Return to Work Sport Hobby Daily Living
Pain Increases with: Activity Lying down Sitting Standing Driving Medication
Pain Decreases with: Activity Lying down Sitting Standing Driving Medication
Work Status: Light Duty Off Work Normal Schedule Retired Disabled
Please list any medications you are taking:
What prior tests/treatment have you had for this problem?
MRI Physical Therapy
CT Scan Injections
Bone Scan Other (please describe)
Numbness //// Moderate
Pain XX Severe Pain Shooting Pain
Numbness //// Moderate Pain XX
Severe Pain Shooting Pain
Current pain severity (please circle one): None 0
1 2 3
4 5 6
7 8 9
10 Worst Is your current condition: Getting better Getting worse staying the same?
Current pain severity (please circle one):
None 0 1 2 3 4 5 6 7 8 9 10 Worst
Is your current condition:
Getting better Getting worse staying the same?
All information is true and correct to the best of my knowledge.
Patient Signature Today’s Date