Health History Form
Date____________
BMI
Name______________________________ Date of Birth_________ Weight _______ Height___________________
Referring Provider/Primary Care Provider_________________________________ Date of last exam__________
Whom may we thank for recommending you to Cornerstone Physical Therapy? ___________________________
Reason for today’s visit_________________________________ Pain Scale: 0 1 2 3 4 5 6 7 8 9 10
No Pain
Please shade in area’s of pain
Severe Pain
Aggravating Factors:
Alleviating Factors:
 Sitting
 Coughing
 Walking
 Exercise
 Lying Down
 Other___________
 Sitting
 Heat/Cold
 Walking
 Exercise
 Lying Down
Other___________
Medications: (List all prescription, non-prescription, and supplements, include doses or attach list if available)
Name
Dose
Reason
Route(oral, inhaler, etc)
Allergies: (latex, medications, food, other-list reaction)_______________________________________________________
Surgery: (c-section, orthopaedic, joint replacement, etc)_____________________________________________________
Imaging: X-Rays, MRI, CT (Specify by name & dates of studies & results if known)_______________________________
Have you had any falls in the past year? _____________________________________ If so how many?__________
Have you ever been in a motor vehicle accident or suffered a head trauma?________________________________
Please answer each section below even if information seems unrelated to your current problem.
NECK/JAW/HEAD:
YES
NO
●Do you experience facial pain?


●Do you feel a click or pop when you open
or close your mouth?


●Do you experience weekly headaches?


●Do you wake up with a dry mouth?


●Do you feel pain in the front of your ear,
or ear “fullness” or “ringing”?


●Do you feel tension at the base of your
skull when you turn your head in the
upright position?


●Please list any current/prior orthodontic splints, braces, or
surgeries______________________________________
VISION: Acuity (example 20/20) ________
YES
●Have you had an eye exam in the past year? 
●Do you wear contacts?

●Do you wear glasses?

●Do you wear bifocals/progressives?

●Do you occasionally bump into objects
while walking?

●Do you have difficulty driving at night?

●Do you have blurry vision, vision loss,
or double vision?

●Do you feel dizzy?

Please complete page 2
NO









BREATHING:
●Do you smoke?
●Do you snore?
●Do you have difficulty breathing with
simple activity? (i.e.: going up steps)
●Do you still feel tired after a full night
of sleep?
●Do you have asthma?
●Do you use an inhaler?
●Do you have to sleep in an upright
position?
●Have you been diagnosed with sleep
apnea?
FEET:
●Do you have pain on the bottom of your
feet when you are standing?
●Do you have orthotics, heel lifts, or any
other foot inserts in your shoes?
●Do you feel unstable with one or both of
your ankles?
YES


NO




















PELVIS:
●Do you ever experience small amounts of
urine leakage when you cough, sneeze,
laugh, lift or exercise?
●Do you ever experience small amounts
of urine leakage associated with a strong
sensation of needing to go to the
bathroom?
●Do you make frequent trips to the bathroom
that disrupt your day or do you plan trips out
based on where there are bathrooms?
●Do you have pain, discomfort or pressure
in your pelvic area or lower abdomen when
sitting or standing for long periods of time?
●Do you frequently strain to have a bowel
movement or to empty your bladder?
●Do you limit your fluid intake out of concern
that you may not be able to hold your urine?
YES
NO












Arthritic conditions (OA, RA, etc)_________________
Infection (hepatitis, Lyme disease, etc)_______________
Blood Disorder (Anemia, etc)____________________
____________________________________________
Nutrition (dieting, weight gain, etc)_________________
Cancer (active, remission, dates)___________________
____________________________________________
Emotional (high stress, depression, anxiety, suicide
attempt, addiction, etc)____________________________
_____________________________________________
Neurological (seizure, multiple sclerosis, Guillain-Barre
Syndrome, ALS, stroke, etc)________________________
_____________________________________________
Skin (cellulitis, psoriasis, hives, rash, etc)____________
____________________________________________
Gastrointestinal (gallbladder, Crohn’s, celiac, gluten
sensitivity, etc)_________________________________
Spine/Orthopedic/Bones: (fracture, dislocation,
neck/back problem, motor vehicle injury, etc)___________
_____________________________________________
Heart Condition (heart attack, high blood pressure,
arrhythmia, etc)_________________________________
Women’s Health (pregnancy, menopause, date of last
period, etc)____________________________________
Hormonal (thyroid, osteoporosis, osteomalacia,
etc)__________________________________________
Other:_______________________________________
_____________________________________________
What are your goals for recovery?__________________________________________________________________
Exercise/Recreational Activities: (when injury free)______________________________________________________
________________________________________________________________________________________________
Have you sought any other treatment for your present condition? (another PT, Chiropractic, or Acupuncture, etc)
________________________________________________________________________________________________
(rev 1/13 WV)