Health History Form | Murphy Therapeutic Group

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Welcome
Physiotherapists
Massage Therapists
- Bart Prinsen
- Sara Robbins
Contact Us

Health History FormDee Flynn2020-07-14T20:36:06+00:00

Health History Form

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Health History Form
An accurate health history is important to ensure therapy is safe for you. All information collected is confidential. You will be asked for written authorization for release of any information.
Name*
First Last
Occupation*
Home Tel#:*
Cell#:
Age:*
Address*
Street Address City Province Postal Code
Date of Birth*
MM slash DD slash YYYY
Email*
Family Physician Name:*
Primary Complaint:*

Please check any that apply to you.
Cardiovascular
Please circle/check any that apply to you.
High Blood Pressure*
- Yes
- No
Low Blood Pressure*
- Yes
- No
Heart Condition*
- Yes
- No
Pace Maker*
- Yes
- No
Stroke*
- Yes
- No
Please explain*
Respiratory
Shortness of breath*
- Yes
- No
Chest Pain*
- Yes
- No
Asthma*
- Yes
- No
Bronchitis*
- Yes
- No
Emphysema*
- Yes
- No
Head / Neck
History of Headache*
- Yes
- No
Altered Taste*
- Yes
- No
Vision Disturbances*
- Yes
- No
Hearing Impairment*
- Yes
- No
Migraines*
- Yes
- No

Other Conditions
Diabetes*
- Yes
- No
Dizziness*
- Yes
- No
Thyroid Dysfunction*
- Yes
- No
Liver Dysfunction*
- Yes
- No
Cancer*
- Yes
- No
Epilepsy*
- Yes
- No
Urinary Dysfunction*
- Yes
- No
Depression*
- Yes
- No
Vomiting/Nausea*
- Yes
- No
Recent Infection*
- Yes
- No
Allergies*
- Yes
- No
Please list allergies*

Do you take Insulin?*
- Yes
- No
Blackouts*
- Yes
- No
Kidney Dysfunction*
- Yes
- No
Arthritis*
- Yes
- No
Osteoporosis*
- Yes
- No
Skin Condition*
- Yes
- No
Bowel Problem*
- Yes
- No
Anxiety*
- Yes
- No
Fever/Chills/Sweats*
- Yes
- No

Infectious Diseases
Please list past surgeries and dates*
Please list any other medical conditions*
HIV/AIDS*
- Yes
- No
Tuberculosis*
- Yes
- No
Hepatitis*
- Yes
- No

General Health
Have you had any unexplained weight loss?*
- Yes
- No
Do you have night pain?*
- Yes
- No
Have you ever taken oral steroid medication for more than 2 weeks? (prednisone)*
- Yes
- No
Do you smoke?*
- Yes
- No
How many packs per day?
Do you consume alcoholic beverages?*
- Yes
- No

Please list all current medications and dosages:*
Do you engage in regular exercise?*
- Yes
- No
What type of exercise?
Please include duration and frequency
Do you engage in recreational activities?*
- Yes
- No
Please list activities
Other Health Care
Are you currently receiving any other health care services?*
- Physiotherapy
- Massage
- Chiropractor
- Other
- None
Please tell us what your primary goal of treatment is*
Consent*
I agree to the privacy policy.
Date*
CAPTCHA

Clinic Hours

Monday 8:00am-7:00pm
Tuesday 8:00am-7:00pm
Wednesday 8:00am-4:00pm
Thursday 8:00am-7:00pm
Friday 8:00am-4:00pm

Contact Info

933 Webber Ave
Peterborough, ON K9J 5X9

Phone: 705.741.1711

Fax: 705.741.1768

Email: [email protected]

Web: murphytherapeuticgroup.ca

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