Let’s Get Physical Therapy
35840 Chester Road Suite F
Avon, Ohio 44011
Phone: 440-937-5210
Fax: 440-937-5212
www.letsgetpt.com
Initial Medical Questionnaire
Name of Patient: _________________________________________________________________
First Middle Initial Last
Address of Patient: _______________________________________________________________
Street Name & Number City State Zip
Home Phone Number: ___________________ Work/Cell Number: _________________
Email Address: ___________________________________________________________________
Can we leave a confidential message at your home phone number? Yes______ No_____
Patient Birthday: ________________ *REQUIRED* Male: _____ Female: _____
Emergency Contact: _______________________________________________________________
Emergency Contact’s Cell Phone Number: ________________ Work: ______________________
Do you have a Latex allergy or sensitivity? Yes: __________ No: ___________
Are you taking any medications? Yes: ________ No: __________
If yes, please list them below, with the purpose for the medication (Dosages not required):
_________________________________________________________________________________
What Treatments have you received for this diagnosis? (PT/Injections/Surgery)
_________________________________________________________________________________
Mark an “X” on the line following any disease or condition for which you have been diagnosed.
Asthma: _______ Do you use a Brace or Orthotic: _______
Anemia: _______ Do you have regular pain in a joint: ______
Diabetes: ______ Do you have regular swelling in a joint: ______
Infection: ______ History of Rheumatoid Arthritis: ______
Pain/Tightness in the Chest: ______ History of Osteoarthritis: ______
Stroke: ______ History of Cancer: ______
Shortness of Breath: ______ History of Skin Cancer or Rash: ______
High Blood Pressure: ______ History of Head Injury/Concussion: _______
Pacemaker/Defibrillator: ______ Headaches: ______
Blood Clot History: _______ History of Falling: ______
Heart Murmur: _______ History of Falling: ______
Heart Surgery: _______ Frequent Cramping: ______
Lightheaded or Fainting: ______ As Applicable: Pregnancy/#: ______
Seizure Disorder: ______ Menopause: ______
Epilepsy: ______ Family History: Death before age 50: _____
Fracture: ______ Cancer: _________________
Stress Fracture: ______ Arthritis: ________________
Instability/Fracture of the Spine: ______ Heart Condition: __________
Surgery: _________________________________________________________________