NEW PATIENT MEDICAL PROFILE

Donna Mathisen Barcomb Professional physical therapy

Today's date

Name(Last)

Name(First)

(M.I)

When did your Pain/Problem begin?

Have you had similar problems before?

When?

Have you had Physical Therapy or Home Health Care before?

When?

If so, Where ?

Have you been treated for any other Health Condition in the last year?

If so, please indicate

Please list all hereditary/congenital Medical Conditions

List all Surgeries/Accidents and dates

Name ALL Medications and Dosage that you are currently taking

Do you smoke?

Number of Packs per day

Weekly Alcohol Consumption

Daily Water Consumption

Are you able to sleep through the night?

What activities do you wish you were able to do, but are unable because of the pain/problem that you presently have?

Signature of Patient: