Personal Health History Form

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PERSONAL HEALTH HISTORY

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

Name
Have you seen an orthopedic surgeon before?
Past Medical History
Check any conditions that you currently have or have had in the past:
Have you had cancer?
Could you be pregnant (women in childbearing years only?)
Past Surgical History
Check any orthopedic procedures or surgeries that you have had in the past:
Do you take aspirin?
Current Complaint / Symptoms
How have your symptoms changed since intial onset?
What is the severity of your pain (where 0 = no pain and 10 = worst pain)?
Have you had any imaging for the current impairment?
Are you currently experiencing any of the following symptoms?
Have you had physical therapy for this problem before?
Please indicate the parts where you feel your symptoms:

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.

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Find Us In Houston

We have 4 locations in Texas

MEMORIAL (NEW LOCATION)

9432 Katy Freeway, Suite 470 Houston, TX 77055

Opening Hours

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

EAST DOWNTOWN

2955 Gulf Freeway, Suite B Houston, TX 77003

Opening Hours

  • 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

RIVER OAKS

3311 Richmond Ave, Suite 210 Houston, TX 77098

Opening Hours

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

SUGAR LAND

3527 Hwy 6 Ste 270 Sugar Land TX 77478

Opening Hours

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

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