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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