ITR Physical Therapy Patient Medical History

21 Montebello Rd, Pueblo, CO 81001

Phone: (719) 546-0037 Fax: (719) 546-0039

Referring Physician: ________________________________ Family Physician: ________________________________

Date of First Doctor Visit for this Injury: ____________ Is an attorney involved in this case? Yes No

Number of surgeries you have had for this injury: 0 1 2 3 Other __

Type of surgery: _________________________________ Date:________ Took place in: Hospital Surgery Center

Are you currently taking any prescription or non-prescription medication? Yes No

List Medications: Anti-inflammatory _____________________ Muscle Relaxers _____________________ Pain Medication _____________________

Have you had any of the following Medical or Rehabilitative Services for this injury/episode?

Have or ever had any of the following?	Yes	No		Yes	No
Asthma, Bronchitis or Emphysema	_____	_____	Severe or Frequent Headaches	_____	_____
Shortness of Breath/Chest Pain	_____	_____	Vision or Hearing Difficulties	_____	_____
Heart attack/Coronary/Angina	_____	_____	Numbness or Tingling	_____	_____
Do you have a Pacemaker?	_____	_____	Dizziness or Fainting	_____	_____
High Blood Pressure	_____	_____	Weakness	_____	_____
			Weight Loss/Energy Loss	_____	_____
Stroke/TIA	_____	_____	Hernia	_____	_____
Blood Clot/Emboli	_____	_____	Varicose Veins	_____	_____
Epilepsy/Seizures	_____	_____	Allergies	_____	_____
Thyroid Trouble/Goiter	_____	_____	Any Pins or Metal Implants	_____	_____
Anemia	_____	_____	Joint Replacement	_____	_____
Infectious Diseases	_____	_____	Neck Injury/Surgery	_____	_____
Diabetes	_____	_____	Shoulder Injury/Surgery	_____	_____
Cancer or Chemotherapy	_____	_____	Elbow/Hand Injury/Surgery	_____	_____
Arthritis/Swollen Joints/Gout	_____	_____	Back Injury/Surgery	_____	_____
Osteoporosis	_____	_____	Hip/Knee Injury/Surgery	_____	_____
Parkinsons	_____	_____	Leg/Ankle/Foot Injury/Surgery	_____	_____
Emotional/Psychological Problems	_____	_____	Are you pregnant?	_____	_____
Bowel or Bladder Problems	_____	_____	Do you smoke?	_____	_____

List any other information that would assist us in your care:

___________________________________________________________________________________________________________________________

What are your expectations/goals while in this program?

___________________________________________________________________________________________________________________________

Signature: ________________________________ Parent/Guardian Signature: ________________________________ Date: ____________________