NEW PATIENT INTAKE FORM – MEDICAL HISTORY

    Name:

    THIS SPACE IS FOR OFFICE USE ONLY

    Date:


    Cardenas & Associates Physical Therapy

    5359 Balboa Blvd., Unit A

    Encino, California 91316

    Phone: (818) 506-7821

    Fax: (818) 506-6722

    The following information will help guide your physical therapist’s evaluation of your problem.

    Use the following symbols to mark the location(s) of your symptoms (pain, numbness, etc.) on the body chart to the right:


    Pain = PPPP

    Numbness = NNNN

    Tingling = TTTT

    Burning = BBBB

    Swelling = SSSS


    Rate your Pain Intensity. Circle one number to indicate how much pain you have at best and one number to indicate how much pain you have at worst.

    012345678910

    Please respond to all the items below related to your general health.


    Acid Reflux
    CurrentlyIn the pastNever
    Anxiety Problems
    CurrentlyIn the pastNever
    Alcohol Abuse
    CurrentlyIn the pastNever
    Asthma
    CurrentlyIn the pastNever
    Cancer
    CurrentlyIn the pastNever
    Chronic Fatigue Syndrome
    CurrentlyIn the pastNever
    Congestive Heart Failure
    CurrentlyIn the pastNever
    Diabetes
    CurrentlyIn the pastNever
    Depression
    CurrentlyIn the pastNever
    Fever
    CurrentlyIn the pastNever
    Fibromyalgia
    CurrentlyIn the pastNever
    Fracture
    CurrentlyIn the pastNever
    Heart Attack
    CurrentlyIn the pastNever
    Heat Sensitivity
    CurrentlyIn the pastNever

    High Blood Pressure
    CurrentlyIn the pastNever
    High Cholesterol
    CurrentlyIn the pastNever
    Incontinence
    CurrentlyIn the pastNever
    Infection
    CurrentlyIn the pastNever
    Irregular Heartbeat
    CurrentlyIn the pastNever
    Metal Implants
    CurrentlyIn the pastNever
    Osteoporosis
    CurrentlyIn the pastNever
    Recreational Drug Use
    CurrentlyIn the pastNever
    Seizures
    CurrentlyIn the pastNever
    Sexual Dysfunction
    CurrentlyIn the pastNever
    Smoking
    CurrentlyIn the pastNever
    Stroke
    CurrentlyIn the pastNever
    Thyroid Problems
    CurrentlyIn the pastNever
    Ulcers
    CurrentlyIn the pastNever


    Have you undergone any
    surgeries?

    NoYes

    Please list:

    Are you taking any
    medications?

    NoYes

    Please list:

    Are you taking any vitamins
    or herbal supplements?

    NoYes

    Please list:

    PATIENT or GUARDIAN SIGNATURE:


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