Health History

About you

Full name

Date

Date of birth

Height

Weight

Referral

Handedness

RightLeft

Primary care physician

Occupation

Do you have access to a health club or swimming pool?

Medical history

Are you currently being treated for, or have you in the past been treated for, any of the following?

If yes to any of the above, please explain

Major surgeries — type and date (most recent first)

Current medications

Vitamins or supplements

Your concern

What brings you in to see OPT?

Onset of your concerns

Have you had this before?

If so, how was it treated?

What would you like to accomplish with this course of care?

Tap the diagram to highlight areas of concern

What is the nature and location of your primary concern?

What makes it worse?

What makes it better?

Is it constant or intermittent?

ConstantIntermittent

Do you feel different from morning to evening?

YesNo

Sleep

Are you sleeping well?

YesNo

Quality hours per night

Side sleeper?

YesNo

What position do you classically sleep in?

Physician evaluation

Has this concern been evaluated by a physician?

If yes, were diagnostic tests taken? (X-ray, MRI, etc.)

Your information is confidential. Questions about billing? Call A.C.E. Billing at 952.922.9121.