Pelvic/Hip Pain Medical Screening Questionnaire Name______________________________Date of Birth____________Date __________ Have you recently had a trauma such as a fall? Y/N Have you ever had a medical practitioner inform you that you have osteoporosis? Y/N Have you ever had a medical practitioner inform you that you have problems with the blood circulation to your hips? Y/N Are you currently or have you been recently on prolonged corticosteroid therapy? Y/N Does your pain ease when you are resting in a comfortable position? Y/N Do you have a past or current history of cancer? Y/N Within the last six months have you gained or lost a substantial amount of weight for no apparent reason? Y/N Have you had any recent changes in your bowels or inability to control your urine? Y/N Do you have groin or thigh pain that increases when you sneeze? Y/N Have you experienced any pain during your last menstrual cycle? Y/N Have you been experiencing anything unusual or out of the ordinary? Y/N If any of the above answers change over the course of your sessions at Revolution Physical Therapy please inform a physical therapist.