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HOUSTON’S LEADER IN MYOFASCIAL RELEASE AND MOVEMENT THERAPY

(832) 831 – 4188

BOOK AN APPOINTMENT

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Personal Health History

This form will be a part of your medical record. Upon completion, please sign the last page.

Last Name *

First Name *

Middle Name *

Date *

Who is your primary physician *

Phone *

Have you seen an orthopedic surgeon before? *

Yes
No

If yes, Physician's Name

Phone

The primary problem that brings me to the clinic is *

Past Medical History

Check any conditions that you currently have or have had in the past:

Anemia
Angina
Asthma
Bleeding Disorder
COPD / Emphysema
Diabetes
Migraines
Epilepsy (seizure)
GERD / Peptic Ulcers
Heart Disease (heart attack, CHF)
Hepatits or Liver Disease
High Blood Pressure
High Cholesterol
Immune Deficiency
Stroke
Multiple Sclerosis
Alcoholosm / Chemical Dependency
Psychiatric Care
Anxiety / Depression / Panic Attack
Tuberculosis
Sleep Apnea
Kidney Disease
Thyroid Disorder

Have you had cancer? *

Yes
No

If Yes, what type and treatment?

Do you have any other medical conditions? *

Could you be pregnant (women in childbearing years only?)

Yes
No

Check any orthopedic procedures or surgeries that you have had in the past:

ACL Reconstruction
Knee Replacement
Shoulder Replacement
Hip Replacement
Knee Arthroscopy (scope)
Spinal Surgeries
Shoulder Arthroscopy (scope)
Ankle Repair
Meniscus Treatment

List any other surgeries or procedures:

List all prescription and non-prescription medication you're currently taking:

Do you take aspirin? *

Yes
No

Current Complaint / Symptoms

How have your symptoms changed since intial onset? *

NO CHANGE
IMPROVED
WORSENED

What is the severity of your pain (where 0 = no pain and 10 = worst pain)? *

0
1
2
3
4
5
6
7
8
9
10

Have you had any imaging for the current impairment? *

X-RAY
MRI
CT SCAN
OTHER
NONE

Are you currently experiencing any of the following symptoms?

NUMBNESS / TINGLING
DIZINESS
POOR BALANCE
NAUSEA
NIGHT PAIN
HEADACHES
SHORTNESS OF BREATH
CHANGE IN BOWEL OR BLADDER FUNCTION

What are you having difficulty doing? (i.e. walking, lifting, sitting)

Have you had physical therapy for this problem before?

Yes
No

If yes, when and where:

Please indicate the parts where you feel your symptoms:

Head
Neck
Hand
Wrist
Forearm
Shoulders
Chest
Belly
Waist
Legs
Knee
Foot

I certify that the above information is correct to the best of my knowledge. I will not hold my therapist or any members of the office staff responsible for errors or omissions that I may have made in completing this form.

Signature of Patient / Date

Rehab Tailored to

Exceed your Expectations

BOOK AN APPOINTMENT

SPRING BRANCH LOCATION

T: (832) 831-4188
E: info@revolvephysicaltherapy.com

A: 8570 Katy Freeway, Suite 114 Houston, TX 77024 Google Map

MON-WED-FRI: 8:00am – 5:00pm
TUE & THR: 8:00am – 7:00pm
SATURDAY: 8:00am – 12:00pm
SUNDAY: Closed

EAST DOWNTOWN LOCATION

T: (832) 831-4188
E: info@revolvephysicaltherapy.com

A: 2955 Gulf Freeway, Suite B Houston, TX 77003 Google Map

MONDAY: 10:00am – 7:00pm
TUE & THR: 9:00am – 5:00pm
WEDNESDAY: Closed
FRIDAY: 8:00am – 2:00pm
EVERY OTHER SAT: 8:00am – 12:00pm
SUNDAY: Closed

GREENWAY LOCATION

T: (832) 831-4188
E: info@revolvephysicaltherapy.com

A: 3311 Richmond Ave, Suite 210 Houston, TX 77098 Google Map

MONDAY: 9:00am – 5:00pm
TUE & THR: 10:00am – 5:00pm
FRIDAY: 9:00am – 5:00pm
WED-SAT-SUN: Closed

sUGAR LAND LOCATION

T: (832) 831-4188
E: info@revolvephysicaltherapy.com

A: 3527 Hwy 6 Ste 270 Sugar Land TX 77478 Google Map

MONDAY: 9:00am – 5:00pm
TUE & THR: 10:00am – 5:00pm
FRIDAY: 9:00am – 5:00pm
WED-SAT-SUN: Closed

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Personal Health History

Past Medical History

Current Complaint / Symptoms

Exceed your Expectations

SPRING BRANCH LOCATION

EAST DOWNTOWN LOCATION

GREENWAY LOCATION

sUGAR LAND LOCATION

OTHER LINK