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.